Mechanic

 

ASRS Database Report Set

Maintenance Reports

Report Set Description .........................................A ....................................... ..A sampling of reports from aircraft maintenance  personnel. Update Number ................................................ .................................................... ....28.0 Date of Update  ................................................... ..................................................... ..January 29, 2016   Number of Records in Report Set ........................50  Number of New Records in Report Set ...............50  Type of Records in Report Set.............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

 

National Aeronautics and Space Administration

 

 Am es Res earc earch h Cen ter

Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when whe n evaluating these data of the following points. ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System. Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event. After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited. The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.

Linda J. Connell, Director  NASA Aviation Safety Reporting System

 

 

CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences. Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other  participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting reporting will have these limitations related to quantitative statistical analysis. One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least  881  881 such events have occurred in 2010. With these statistical limitations in mind, we  believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

 

Repor portt Synopses Syno pses

 

ACN: 1308695

(1 of 50)

 

Synopsis Two Aircraft Maintenance Technicians (AMTs) (AMTs) report a right Main Landing Gear (MLG) on a Fairchild (Swearingen) SA-227DC Merlin had collapsed as the aircraft was towed into the hangar across an asphalt to concrete transition line. Three of the four bolts attaching one of the two crescent shaped cams on the right MLG were found sheared.

ACN: 1307353

(2 of 50)

 

Synopsis A Maintenance Technician reported a nose landing gear collapse when the tug was unintentionally accelerated in reverse.

ACN: 1305894

(3 of 50)

 

Synopsis A Maintenance Technician reported that following the deferral of an engine driven hydraulic, the aircraft experienced an inflight engine shutdown due to the loss of engine oil.

ACN: 1304978

(4 of 50)

 

Synopsis A lead Maintenance Technician reported a process failure where propeller blades were installed in the incorrect position during build-up, build -up, resulting in vibration when the assembly was installed on an aircraft.

ACN: 1301789

(5 of 50)

 

Synopsis A Line Aircraft Maintenance Technician reports that ramp personnel performing wing walker duties do not stayfuel withsavings inbound aircraft at thecompany, arrival gate until ground power been established. A new policy by their requires flight crews tohas continue running the #1 Engine on B737NGs and A320 aircraft instead of using the APUs; raising safety concerns for personnel and equipment behind the aircraft.

ACN: 1300292

(6 of 50)

 

Synopsis A Maintenance Technician reported impacting a hangar during taxi when the nosewheel steering system and brake system were disabled by the unreported activation of the landing gear squat switch.

ACN: 1299377 Synopsis

(7 of 50)

 

 

A Maintenance Inspector reported the loss of an aileron hinge pin during a test flight following adjustments for an out of trim condition.

ACN: 1299325

(8 of 50)

 

Synopsis A Maintenance Technician described an engine high power run where the parking brake became released, which resulted in the propeller contacting a piece of ground equipment.

ACN: 1299093

(9 of 50)

 

Synopsis A Maintenance Technician reported that maintenance paperwork paperwork had been left in the work area and caused a subsequent binding of the rudder cables.

ACN: 1297551

(10 of 50)

 

Synopsis A Maintenance Controller describes the results of effective maintenance troubleshooting after a Dassault-2000 flight crew reports their flap Circuit Breakers (CBs) had popped on approach. Technicians found flap torque tubes had disconnected at the right wing trailing edge between the Inboard (IB) and Outboard (OB) flaps.

ACN: 1295814

(11 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) with extensive DC-10 Engine Reverser experience describes what he believes to be inaccurate Boeing Lamm schematics that have contributed to engine pneumatic lines being attached at incorrect positions on Dual Switcher Valves on GE-CF6-80 engines. The Switcher Valves are part of the FAAs Thrust Reverser Safety Enhancement System A.D.

ACN: 1295357

(12 of 50)

 

Synopsis Maintenance technicians reported reported that they were notified noti fied of a loose wing panel after a passenger noticed it fluttering in flight. Several fasteners were found missing from the panel.

ACN: 1294332

(13 of 50)

 

Synopsis Several Maintenance Technicians reported difficult working conditions that resulted in maintenance errors including the possible installation of the incorrect part number.

ACN: 1294072

(14 of 50)

 

 

Synopsis A maintenance technician described the conditions that contributed to the installation of an incorrect fan blade.

ACN: 1293413

(15 of 50)

 

Synopsis Maintenance Technician reported that when electrical power was reapplied following the routine replacement of a Metroliner engine fire extinguisher bottle, the bottle was unexpectedly discharged. He revealed that wires had been incorrectly connected due to mislabeling of the wires.

ACN: 1292485

(16 of 50)

 

Synopsis Mechanics and Captain disagreed about the gauge display for the exit doors' pneumatic charge. Different aircraft assigned.

ACN: 1291853

(17 of 50)

 

Synopsis B767 Maintenance Technician was assigned the task of clearing a spoiler deferral, but was unable to do so. The MEL was reinstated, but the spoiler handle was not tested and the aircraft was dispatched with the spoiler restricted to 50% of normal.

ACN: 1291474

(18 of 50)

 

Synopsis After their CRJ-200 aircraft had departed, two Aircraft Maintenance Technicians realized they had installed a new carbon seal O-Ring at the wrong location on # 1 Engine Integrated Drive Generator. # 1 Engine lost all oil in flight. Distraction, inadequate and easy to misinterpret maintenance diagrams, work interruptions from Management, lack of training and experience and a slow on-line Maintenance Manual program were noted as contributors.

ACN: 1290978

(19 of 50)

 

Synopsis Two Aircraft Maintenance Technicians reported recurring Right Main Landing Gear (MLG) L/G Not UNLOCKED ECAM faults on an A320 aircraft. Aircraft ferried to a Line Maintenance Station with limited resources. Right MLG Retract actuator replaced. No Flight Test required. Aircraft departed but returned to field with ECAM Advisory message message FLT L/G DOWN. Found the L/G DOWN VMO (Maximum Operating Speed Limit)/MMO (Maximum Mach Operating Speed) selection switch (22FP) on the 188VU panel inadvertently left in the L/G down position. Reset switch to L/G 'Normal' position.

ACN: 1289759

(20 of 50)

 

 

Synopsis An Aircraft Maintenance Technician reported reported finding a thi third rd Cessna CE-560XLS aircraft in a month with Main Landing Gear Uplock Hook bushings worn during their Post Maintenance Checklist inspections. Technician believed that since they have migrated from doing Phase 1-4 Inspections to performing Phase-A and Phase-B Inspections, the Uplock Detailed Inspection Task has been overlooked.

ACN: 1289753

(21 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) working as an on-call Air Carrier Technical Representative describes his excessively long, irregular work days, ever changing work hours, lack of adequate support for re-scheduling hotels and fatigue from lack of sleep.

ACN: 1289750

(22 of 50)

 

Synopsis An Aircraft Maintenance Technician recommended recommended a specific tool be made or listed in the Aircraft Maintenance Manual Manual for technicians to use to avoid damage to CFM-56 Engine Fan disks when removing the N1 Fan Blade Shim/Keeper weights. Inadvertent tooling damage by Technician required unscheduled engine replacement on a B737-900 aircraft.

ACN: 1288221

(23 of 50)

 

Synopsis A Maintenance Technician lost control of an aircraft following an expedited taxi across a runway with approaching landing traffic.

ACN: 1287823

(24 of 5 50 0)

 

Synopsis An Aircraft Maintenance Technician recommended his Air Carrier fix the malfunctions with their IPAD/Digital communication software program that cleared a 'System-2 Regulator' fault discrepancy instead of deferring the Logbook item.

ACN: 1282992

(25 of 50)

 

Synopsis An Aircraft Maintenance Technician reported about a potential safety risk and improper maintenance documentation practices practices after his Lead and Supervisor directed him to install a faulted and unserviceable GFI Relay into a B747-400 aircraft that needed to be defueled for maintenance. GFI was part of an airworthiness directive to disrupt electrical power to fuel pumps in a fuel tank.

ACN: 1282664 Synopsis

(26 of 50)

 

 

A Maintenance Technician and Inspector describe the events that led up to the loss of engine upper cowling from CRJ-200.

ACN: 1281886

(27 of 50)

 

Synopsis A Maintenance Technician disagreed with a Lead Technician on the use of an electrical conduit repair based upon the extent of the damage.

ACN: 1280088

(28 of 50)

 

Synopsis A Maintenance Technician was advised that the part he replaced several months earlier had been installed incorrectly. The fault was identified by the failure of the horizontal stabilizer operational check during routine inspection.

ACN: 1279377

(29 of 5 50 0)

 

Synopsis A Director of Maintenance and a pilot/mechanic reported that they had been advised of a missed inspection signoff for an internal engine component, but that in discussion with a FAA Principal Maintenance Inspector, the part was airworthy with the time remaining. Later, the conclusion was questioned by another Principal Maintenance Inspector and was under investigation.

ACN: 1278743

(30 of 50)

 

Synopsis A Maintenance Inspector discovered that the Maintenance M aintenance Supervisor was incorrect when he reported that all of the t he engine change paperwork was completed when he requested the final signoff.

ACN: 1278430

(31 of 50)

 

Synopsis A distracted and overworked MD-82 Mechanic forgot to close the nose gear door following foll owing a maintenance procedure the previous evening. After takeoff the next morning a severe hydraulic system shudder during gear retraction caused caused the fli flight ght crew to lower the gear and return to the departure airport.

ACN: 1278065

(32 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) reports reports he did not include any Aircraft Maintenance Manual (AMM) reference in a logbook sign-off for replacement of a parking brake light on a B737 that had illuminated intermittently at cruise with the parking brake 'off.'

 

ACN: 1277957

(33 of 50)

 

Synopsis A Maintenance Technician neglected to fully ful ly remove power from the battery charger, resulting in shorting of the contact terminal that required replacement.

ACN: 1277063

(34 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) reports finding the landing gear control cables in the forward cargo pit ceiling wrapped around each other at approximately frame station 300 on a B767-300 aircraft. Pilots had made several previous write-ups for a stiff gear handle with a "grinding noise and feel." A floor beam repair had recently been accomplished that removed the cables. 'Clearance to Close' panels also an issue.

ACN: 1275197

(35 of 50)

 

Synopsis An MD-80 had normal seats installed in two of the emergency exit seat rows. The seatback tray tables could block the emergency exits.

ACN: 1274898

(36 of 50)

 

Synopsis A Maintenance Controller reports about events surrounding an inappropriate deferral of an APU for an EICAS L BLEED LEAK WARNING on a CRJ-900 aircraft at an outstation gate. Controller also noted the significant lack of knowledge maintenance controllers have of the pneumatic system, the untrained, ill equipped outstation mechanics, and the lack of effective troubleshooting the cause of the EICAS warning.

ACN: 1274892

(37 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) was informed he had failed to completely review the Maintenance Procedures previously accomplished under MEL 28-XX-XX, when a Defueling Valve was found still safety wired closed after he had cleared the MEL. The deferral had noted when selecting the Fuel Transfer switch on the Overhead panel to 'LOW', fuel would be supplied not only to the engine selected, but also to that side's wing tank.

ACN: 1274216

(38 of 50)

 

Synopsis A Quality Assurance (QA) Lead Technician reports about one of their AS-350 Eurocopter's that was placed back in service with overdue Airframe and Powerplant 100-Hour and 700Hour inspection items not completed. His company operations had contracted with a news gathering organization to provide an AS-350 on short notice. He notified his hi s Director of

 

Maintenance (DOM) about the non-compliance, but the response was not very supportive of his concerns.

ACN: 1274075

(39 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) reports not feeling comfortable with an order from their Maintenance Supervisor to stop all testing and reassemble all the items they had taken apart after an Altitude Pressure switch had failed and an EPR leak was discovered on a B757-300 aircraft. The supervisor canceled the Job Cards and noted the technicians involved were not operating equipment correctly. Replacement for a failed Altitude Pressure switch was not available.

ACN: 1273178

(40 of 50)

 

Synopsis A Line Aircraft Maintenance Technician (AMT) reports how a standard task card procedure to check APU oils on their wide bodied aircraft within one hour of arrival by using the EICAS page to determine if oil servicing was necessary, necessary, did not satisfy the requirement to visually check the APU oil sight-glass for ETOPS flights. The B767-300 was originally origi nally scheduled Out of Service (OTS), but later had an ETOPS flight scheduled.

ACN: 1272208

(41 of 50)

 

Synopsis A Line Aircraft Maintenance Technician (AMT) describes his frustration and safety concerns surrounding a manual engine start procedure on the ramp with limited personnel and having to use hand signals without a standard set of guidelines for everyone to follow. Headsets could not be connected to the MD-82 aircraft due to weather conditions.

ACN: 1272205

(42 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) was was informed by a company pilot that one of their Bell BHT-407 helicopters had a 'FADEC Degraded' light illuminate in flight. The intermittent fault would occur every ten to twelve hours and had been an on-going problem for months that could not be duplicated dupli cated in the hangar.

ACN: 1272196

(43 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) recommends an additional reference be added to Airworthiness Directive (AD) 2012-11-09 to include Illustrated Parts Catalog (IPC) 3521-01-40b, (item C). The IPC would provide a better understanding of the Passenger O2 mask box release cable routing. Misunderstanding of Step 2 of the AD resulted in an incorrect installation of the release cable and O2 masks on a B777-200 aircraft.

ACN: 1271618

(44 of 50)

 

 

Synopsis An Aircraft Maintenance Technician (AMT) reports finding a B737 weather radar unit 'On' and running in the hangar during aircraft maintenance. Technician noted the need for documentation to protect workers from the health hazards of radar operations should also include pulling the Radar Circuit Breaker (C/B) before maintenance is performed.

ACN: 1270807

(45 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) reports about his Maintenance Manager who continually attempts to cover up discrepancies with the aircraft they have at their Flight Facility. Technician also includes examples of the same Manager applying pressure to perform maintenance or modifications to their aircraft, not in compliance with their Practices and Procedures Manuals.

ACN: 1270752

(46 of 5 50 0)

 

Synopsis An Aircraft Maintenance Inspector reports using LED Ultraviolet Ul traviolet type lights for Fluorescent Penetrant Inspection (FPI) of Rolls Royce Engine parts for more than two years, believing an Engineering Variance had been issued to allow the use of the LED lights. li ghts.

ACN: 1270457

(47 of 50)

 

Synopsis A Line Aircraft Maintenance Technician (AMT) reports about an unrecognized critical safety issue that exists for pilots to lose control of B757/B767 aircraft on approach, if the pilot seat shifts unexpectedly due to broken Seat Track Lock Control assemblies. Technician suspects the routine seat inspection task card is not sufficient to maintain adequate serviceability of crew seats.

ACN: 1270323

(48 of 50)

 

Synopsis

Two Maintenance Controllers, an Aircraft Maintenance Technician (AMT) and a Captain describe their involvement with a reported # 2 Engine Fuel Spar Valve Overhead Blue light fault that was miscommunicated and deferred as an Engine Valve Blue fault light on a B737-800 aircraft. A downline Maintenance Station noted that the original discrepancy discrepancy and the resolution did not match. Spar valve was replaced and Engine Valve MEL cleared.

ACN: 1270315

(49 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) reports reports placing a 2" x 4" board against the outer lip of the Left Main Landing Gear (MLG) door after completing a Center Axle alignment on a B777 aircraft. MLG door was closed later, but the 2X4 fell out of the wheel well after takeoff also staffing told from the contributors. perspective of the Captain of the flight. Di Distractions, stractions, work workload load and limited were

 

ACN: 1269736

(50 of 50)

 

Synopsis An Aircraft Maintenance Technician (AMT) reports reports about the efforts made to llocate ocate a 1/4" inch drive, 7/16" inch shallow socket that was unaccounted for after a Forward (FWD) Fuel Cell replacement on a Bell BHT-407 helicopter. Inspections of critical areas that would effect safety of flight were accomplished; socket not found. Fuel tanks were not drained. Training Flight crew accepted aircraft for service.

 

Repo port rt Na Narr rraatitives ves

 

ACN: 1308695

(1 of 50)

 

Time / Day Date : 201511 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : SA-227 AC Metro III Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 135 Flight Plan : IFR Mission : Passenger Flight Phase : Parked Maintenance Status.Released For Service : N Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Inspection Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Testing

Component : 1 Aircraft Component : Main Gear Manufacturer : Fairchild/Swearingen Aircraft Reference :X Problem : Failed

Component : 2 Aircraft Component : Gear Extend/Retract Mechanism Manufacturer : Fairchild/Swearingen Aircraft Reference : X Problem : Malfunctioning

Person : 1 Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Taxi Function.Maintenance : Lead Technician Qualification.Maintenance : Powerplant

 

Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1308695 Human Factors : Confusion Human Factors : Time Pressure Analyst Callback : Completed

Person : 2 Reference : 2 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Taxi Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1308696 Human Factors : Confusion

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Ground Event / Encounter : Ground Strike - Aircraft Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Taxi Result.General : Maintenance Action Result.Aircraft : Aircraft Damaged

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Aircraft Primary Problem : Aircraft

Narrative: 1 Was brought out to tow aircraft to hangar for hangar installation. Hooked up tow bar after shutdown, hooked tug to towbar, got okay to tow, wing walkers wal kers thumbs up, towing was successful until aft right Main Landing Gear (MLG) tires hit a small one inch lip at asphalt to concrete change point, right main gear folded at this point and right side of aircraft hit the ground asphalt/concrete. It was discovered that the cause of the problem was shearing of the main gear cam bolts. My only recommendations are a fleet campaign and or, if the problem proves to be affiliated with specific design of the aircraft possibly a Service Bulletin (SB) or Airworthiness Directive (AD) that makes the change of the bolts at regular intervals mandatory. Towing after ferry flight.

Callback: 1 Reporter stated his air taxi has already started a fleet campaign to check the four bolts and self-locking nuts that attach two crescent moon shaped cams on the forward drag brace of each main gear strut. Two hydraulic actuators one for (up) and one for the (down) movement of each Main Landing Gear (MLG) have a bearing that ride iin n the crescent section and rotate the MLG. The Main Landing Gears do not use a traditional overcenter locking brace. Reporter stated the Fairchild (Swearingen) Merlin had just arrived after a ferry flight for a

 

landing gear door system problem. The prop, nose cone and planetary gears were damaged after the MLG collapsed. Three of the four cam attach bolts at one of the two cams for the right gear had completely sheared and the fourth was half sheared. He suspects that was an isolated incident, but is also aware the cam bolts are not normally removed and inspected for condition during Maintenance checks. He believes bel ieves the Main Landing Gears had been changed recently. Aircraft should be jacked up to replace the bolts. He recommends at least a torque check of the cam bolts and self-locking nuts which may indicate if some have already sheared.

Narrative: 2 I was walking in, the right ri ght wing of the aircraft, as iitt was being pushed back into the hangar, the right Main Landing Gear (MLG) collapsed and the right wi wing ng hit the ground in front of me. [Recommendations]: Nothing comes to mind since any defects were unknown at time of occurrence [during] aircraft push back into hangar.

Synopsis Two Aircraft Maintenance Technicians (AMTs) report a right Main Landing Gear (MLG) on a Fairchild (Swearingen) SA-227DC Merlin had collapsed as the aircraft was towed into the hangar across an asphalt to concrete transition line. Three of the four bolts attaching one of the two crescent shaped cams on the right MLG were found sheared.

 

ACN: 1307353

(2 of 50)

 

Time / Day Date : 201510 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Medium Large Transport, Low Wing, 2 Turbojet Eng Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : N

Component Aircraft Component : Nose Gear Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant Experience.Maintenance.Technician : 17.5 ASRS Report Number.Accession Number : 1307353 Human Factors : Situational Awareness Human Factors : Distraction Human Factors : Confusion

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Ground Strike - Aircraft Detector.Person : Maintenance When Detected.Other Result.General : Maintenance Action Result.Aircraft : Aircraft Damaged

Assessments Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1

 

I was pushing aircraft to park at hangar. Once chocked was going to pull the push tractor back and in to set it up for a crewmate to pull the pin out. As I thought I had my foot on the brake had it on the accelerator, the tractor lunged backwards and pulled the front nose strut out and the aircraft collapsed. Nobody was injured and all were safe.

Synopsis A Maintenance Technician reported a nose landing gear collapse when the tug was unintentionally accelerated in reverse.

 

ACN: 1305894

(3 of 50)

 

Time / Day Date : 201509 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Regional Jet 700 ER/LR (CRJ700) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Parked

Component : 1 Aircraft Component : Powerplant Lubrication System Aircraft Reference : X Problem : Failed

Component : 2 Aircraft Component : Hydraulic System Pump Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization :: Technician Air Carrier Function.Maintenance Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1305894 Human Factors : Situational Awareness Human Factors : Confusion Human Factors : Troubleshooting

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew Result.General : Maintenance Action

 

Result.Flight Crew : Diverted Result.Flight Crew : Inflight Shutdown

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Ambiguous

Narrative: 1 We were called out to aircraft for a #1 hydraulic system quantity low. Serviced the #1 system in accordance with Aircraft Maintenance Manual (AMM). We noticed Skydrol leaking out of the #1 engine drain port. Opened the #1 engine cowl and found the #1 Engine Driven Pump (EDP) to be leaking when the engine was motored over. Proceeded to remove and perform deactivation procedures of the #1 EDP in i n accordance with AMM. After completion of the deactivation ran the #1 engine for leaks and no n o leaks were noted. Aircraft was then dispatched with a #1 EDP deferred. Aircraft was dispatched with a #1 EDP [deactivated] and was diverted due to #1 engine loss of engine oil resulting in engine shut down. It would be better if the AMM would be more detailed in the leak check procedure.

Synopsis A Maintenance Technician reported that following the deferral of an engine driven hydraulic, the aircraft experienced an inflight infli ght engine shutdown due to the loss of engine oil.

 

ACN: 1304978

(4 of 50)

 

Time / Day Date : 201510 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : SF 340A Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Component : 1 Aircraft Component : Propeller Assembly Aircraft Reference : X

Component : 2 Aircraft Component : Propeller Blade Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Lead Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1304978 Human Factors : Confusion Human Factors : Situational Awareness Human Factors : Time Pressure Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance Result.General : Maintenance Action

Assessments

 

Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Ambiguous

Narrative: 1 I was the lead mechanic for a propeller build-up during which #2 and #4 blades were swapped. When the prop was finally on a plane a month later, theand airplane experienced excessive vibration. Thisput is when the prop was inspected found that blades were installed in the wrong locations. I think the blades were installed improperly because too many people were involved in the build-up. build -up. Blades #1 and #3 were install installed ed first so I think we just got confused as to which side #2 went on. Inevitably after installing #2 incorrectly, then #4 would also be incorrect. I think we also failed to double-check our work like we did when installing #1 blade.

Synopsis A lead Maintenance Technician reported a process failure where propeller blades were installed in the incorrect position during build-up, resulting in vibration when the assembly was installed on an aircraft.

 

ACN: 1301789

(5 of 50)

 

Time / Day Date : 201510 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737 Next Generation Undifferentiated Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Taxi

Component Aircraft Component : Engine Exhaust System Aircraft Reference : X

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1301789 Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Time Pressure Human Factors : Confusion Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Ground Personnel

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Other / Unknown Detector.Person : Maintenance Were Passengers Involved In Event : N

 

When Detected : Aircraft In Service At Gate Result.General : None Reported / Taken

Assessments Contributing Factors / Situations : Staffing Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Primary Problem : Company Policy

Narrative: 1 We have been having personnel safety issues regarding jet blast from inbound flights getting parked at the terminal gates. The Wing Walker of an inbound flight leaves his or her post after the aircraft is inside the gate envelope, rendering the Wing Wal Walker ker duty void. After an inbound flight is inside the gate envelope the Wing Walker follows the aircraft for other duties, leaving the traffic zone [exhaust] area behind the aircraft unattended. Usually, with a lengthy void of unattended Wing Walker duty, the traffic t raffic unaware, starts to cross behind the running engine (other waiting traffic has already turned around to find other alternative route). This has caused repeated jet blast conditions, it is a matter of time when a serious injury will occur. Other Aircraft Maintenance Technician (AMTs) or Aircraft Electronics Technician (AETs) have voiced concerns to the matter with no avail. avail . The main concern of this report is to get Wi Wing ng Walkers to stay at their post till engines shut down. I want to bring up a safety saf ety issue addressing Ramp Tower, Idl Idle e Engine Run Safety on the Terminal Gates. I have filed a report and have discussed the issue with some management personnel from my department (Aircraft Maintenance) and some Ramp safety personnel over the last few months, but I thought it might be a good idea to include ATC, L Local ocal Air Carrier Ramp Tower Management also, concerning this issue. [Our] Air Carrier's new Fuel Savings Policy: (Flight crews on incoming flights for NG737, A319/320 aircraft are required to pull onto gate [with] APU OFF and continue to Run #1 Engine until Ground Power is connected and verified online before shutting down # 1 Engine.) This practice has been in i n force for a few months now and there are a re many safety concerns and problems that have arisen due to the # 1 engines extended Run times on the Gate. What is supposed to take place in about 30-seconds (Hook up GRD PWR/ Shut down # 1) has been observed by many of us to t o take up to two minutes or more as problems arise hooking up Ground Power. During this thi s extended Engine Run Time, I and others have reported to Management on more than one occasion, Safety Safet y Hazards related to the extended engine run time. 50% of the time there is no safety Wing Wi ng walkers with safety wands giving the warni warning ng signal of a running engine to Ground personnel. Several incidents of Ground personnel driving behind near, or on foot, near the running engine. On windy days I have personally seen paper FOD blown near the inlet of the running engine and getting ingested causing me to later inspect the inlet and remove debris in # 1 Engine. Myself and others I have talked to (including Flight crews) being under the duress of concern that it's just a matter of time before someone or something large gets ingested i ngested into # 1 Engine. Little if any significant fuel savings to justify the risks involved of the extended # 1 Engine run time. As far as I know, there is i s still no written Safety S afety Policy in effect for Ground personnel to support the new Fuel Savings Policy. I had a Ramp person tell me that this new policy does not require in writing, [that] Wing Walkers stay behind the aircraft's Left side with

 

safety wands to warn other Ground personnel pers onnel of the Running Engine? So, some Ramp personnel refuse to do it. So, after they wing walk and the brakes are set, they just drop their wands and walk away with the # 1 Engine still Running. Pounds per Hour (PPH) the APU burns less fuel than a running engine? When Maintenance performs an engine run on the gate for maintenance reasons, we have to get permission permi ssion from Ramp Tower on radios and we are required to have safety Ground personnel with wands in place tto o warn Ground personnel of the running engine. The Jet ways are being brought up to the aircraft while the engine is still running on many occasions.

Synopsis A Line Aircraft Maintenance Technician reports that ramp personnel performing wing walker duties do not stay with inbound aircraft at the arrival gate until ground power has been established. A new fuel savings policy by their company, requires flight crews to continue running the #1 Engine on B737NGs and A320 aircraft instead of using the APUs; raising safety concerns for personnel and equipment behind the aircraft.

 

ACN: 1300292

(6 of 50)

 

Time / Day Date : 201510 Local Time Of Day : 1201-1800

Place Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : Citation X (C750) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 135 Mission.Other Flight Phase : Taxi

Component : 1 Aircraft Component : Squat Switch Aircraft Reference : X Problem : Improperly Operated

Component : 2 Aircraft Component : Normal Brake System Aircraft Reference : X Problem : Malfunctioning

Component : 3 Aircraft Component : Parking Brake Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location In Aircraft : Flight Deck Reporter Organization : Air Taxi Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1300292 Human Factors : Situational Awareness Human Factors : Troubleshooting Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Less Material Severe / Policy Anomaly.Deviation - Procedural : Published

 

Anomaly.Deviation - Procedural : Maintenance Anomaly.Ground Event / Encounter : Object Anomaly.Inflight Event / Encounter : Object Detector.Person : Maintenance Result.Flight Crew : Took Evasive Action Result.Aircraft : Aircraft Damaged

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Ambiguous

Narrative: 1 The aircraft was not on [the [ the FBO] ramp but we saw it i t on the customs ramp. We got to th the e aircraft and started a walk around. I plugged in the batteries and pull pulled ed the main chock. The other technician hooked up the torque links. I got in the aircraft in the pilot seat and looked over the CB panel and the various switches swi tches in the cockpit. I turned the batteries on. I turned the aux hydraulic switch on the buildup press and set the brakes. With brakes set the nose chock was pulled. I started the APU and got the generator on line. I turned on the inverters and turned on the AHRS [attitude and heading reference system] and power supply. With avionics up I started the right hand engine. With the engine running and amps at a good level, I started the left engine. I checked the oil pressures and hydraulic pressures. I called ground [control] for clearance to taxi to [FBO ramp]. With clearance I pushed the brake off and started rolling. I went to turn and had no nose wheel steering. I applied the brakes and had no brakes. I pulled pull ed the parking brake handle and had no results. I was closing in on the hangar in front of me and shut down the engines to avoid damage to the engines. I impacted the hangar right ri ght after that. I shut down the APU and shut down the power. I then got out of the aircraft aircr aft and unplugged the batteries. After a bit of time talking to the [airport personnel] pers onnel] I then thought of squat switches as a possible problem and found the squat switches were manually placed in air mode. Suggestions 1) Documentation of tooling installed on aircraft 2) Flags on all maintenance lockout/pins etc 3) Inspection Buy Back of ground lock devices being removed

Synopsis

A Maintenance Technician reported impacting a hangar during taxi when the nosewheel steering system and brake system were disabled di sabled by the unreported activation of the landing gear squat switch.

 

ACN: 1299377

(7 of 50)

 

Time / Day Date : 201510 Local Time Of Day : 0601-1200

Aircraft Reference : X Aircraft Operator : Personal Make Model Name : Cessna 180 Skywagon Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Mission : Test Flight Flight Phase : Cruise Maintenance Status.Maintenance Deferred : N Maintenance Status.Records Complete : N Maintenance Status.Released For Service : N Maintenance Status.Maintenance Items Involved : Testing

Component Aircraft Aircraft Component Reference : :X Aileron Problem : Malfunctioning

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Personal Function.Maintenance : Inspector Qualification.Maintenance : Airframe Qualification.Maintenance : Inspection Authority Qualification.Maintenance : Powerplant Experience.Maintenance.Inspector : 20 ASRS Report Number.Accession Number : 1299377

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action Result.Aircraft : Aircraft Damaged

Assessments Contributing Factors / Situations : Procedure Primary Problem : Procedure

Narrative: 1

 

Pilot said aircraft was flying out of trim. Maintenance adjusted and flew aircraft after preflight. Trim was adjusted and second flight made. On second flight left hand aileron ail eron moved back from outboard hinge. Aircraft was flown back to airport. Found left outboard hinge pin missing and aileron bent.

Synopsis A Maintenance Inspector reported the loss of an aileron hinge pin during a test fl flight ight following adjustments for an out of trim condition.

 

ACN: 1299325

(8 of 50)

 

Time / Day Date : 201510

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Medium Transport, High Hi gh Wing, 2 Turboprop Eng Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Component : 1 Aircraft Component : Propeller Aircraft Reference : X Problem : Improperly Operated

Component : 2 Aircraft Component : Parking Brake Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1299325 Human Factors : Situational Awareness

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Object Anomaly.Ground Event / Encounter : Loss Of Aircraft Control Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action Result.Flight Crew : Regained Aircraft Control Result.Aircraft : Aircraft Damaged

Assessments

 

Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Ambiguous

Narrative: 1 During a high power performance run, at approximately 96% torque, the parking brake handle released and the plane lurched forward, jumping the chocks. The left engine struck the and damaged thethe #1throttles propeller. The aircraft movement was stopped by applying the GPU toe brakes, retarding and reapplying parking brake. [In the future] chock all three gear, remove GPU from run area.

Synopsis A Maintenance Technician described an engine high power run where the parking brake became released, which resulted in the propeller contacting a piece of ground equipment.

 

ACN: 1299093

(9 of 50)

 

Time / Day Date : 201509 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Regional Jet 700 ER/LR (CRJ700) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Nav In Use : FMS Or FMC Flight Phase : Parked Maintenance Status.Maintenance Deferred : Y Maintenance Status.Records Complete : Y Maintenance Status.Released For Service : Y

Component Aircraft Component : Rudder Control System Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Contracted Service Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe Experience.Maintenance.Technician : 7 ASRS Report Number.Accession Number : 1299093 Human Factors : Situational Awareness

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person Flight Crew When Detected ::In-flight

 

Result.General : Maintenance Action Result.Flight Crew : Overcame Equipment Problem

Assessments Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I was called out to defer the L/H wing anti-ice valve per MEL on a CRJ-700. The work was completed but I apparently left the MEL manual paperwork in the area of the valve. Later the flight crew made a maintenance discrepancy di screpancy that they felt binding in the rudder. The paperwork that was left in the valve area had worked its way to the flight control cables and was rubbing against the rudder cables. To prevent a recurrence I will wi ll double check that all paperwork has removed after the work has been complete.

Synopsis A Maintenance Technician reported that maintenance paperwork had been left in the work area and caused a subsequent binding of the rudder cables.

 

ACN: 1297551

(10 of 50)

 

Time / Day Date : 201509 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Fractional Make Model Name : Falcon 2000 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 135 Flight Phase : Parked Maintenance Status.Maintenance Maintenance Status.Maintenance Maintenance Status.Maintenance Maintenance Status.Maintenance Maintenance Status.Maintenance Maintenance Status.Maintenance

Deferred : N Type : Unscheduled Maintenance Items Involved : Repair Items Involved : Installation Items Involved : Inspection Items Involved : Testing

Component : 1 Aircraft Component : Flap Control (Trailing & Leading Edge) Manufacturer : Dassault Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Flap/Slat Control System Manufacturer : Dassault Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Fractional Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1297551 Human Factors : Communication Breakdown

 

Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance Detector.Person Flight Crew Were Passengers: Involved In Event : N When Detected : In-flight Result.General : Maintenance Action Result.Flight Crew : Overcame Equipment Problem

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 On approach, the crew noted that the flap Circuit Breakers (CBs) were popped; landing was uneventful. daysuch of waiting on parts and changing Printed Boards (PCBs), (normal After actionafor a squawk). Technicians inspected the Circuit flaps and noted the following: Continued investigation into flap issue on [the] Aircraft, a Falcon DA-2000. After removing right wing Inboard (IB)/ Outboard (OB) flap junction fairings, found OB flap impacting flap interconnect control rod and trailing edge of the OB flap below the IB flap. Upon comparison to left wing found IB flap travel greater than OB flap. Removed trailing edge panel on right wing, between IB and OB flap and found torque tubes disconnected. Only speculation, but when the aircraft recognized a [difference], it stopped the flap movement; but because OB flap was disconnected, dis connected, it continued to spool down for some reason where it impacted IB flap interconnect rod. r od. Bolt in flap torque tube appears to be ful fully ly installed in clamp with locking washer properly installed. I suspect when torque tubes were last removed the bolt was not engaged in the groove on the spline spli ne upon reinstallation therefore allowing the torque tubes to migrate apart over time. [Recommend] [clearance] (okay to close) and final Required Inspection Items (RII) inspections should be followed.

Synopsis A Maintenance Controller describes the results of effective maintenance troubleshooting after a Dassault-2000 flight crew reports their flap Circuit Breakers (CBs) had popped on approach. Technicians found flap torque tubes had disconnected at the right wing trailing edge between the Inboard (IB) and Outboard (OB) flaps.

 

ACN: 1295814

(11 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : DC-10 Undifferentiated or Other Model Operating Under FAR Part : Part 121 Flight Phase : Parked Maintenance Maintenance Maintenance Maintenance Maintenance Maintenance Maintenance

Status.Maintenance Deferred : N Status.Released For Service : Y Status.Maintenance Type : Scheduled Maintenance Status.Maintenance Items Involved : Work Cards Status.Maintenance Items Involved : Testing Status.Maintenance Items Involved : Installation Status.Maintenance Items Involved : Inspection

Component : 1 Aircraft Component : Pneumatic Valve/Bleed Valve Manufacturer : Middle River Aircraft Systems Aircraft Reference : X Problem : Improperly Operated Problem : Malfunctioning

Component : 2 Aircraft Component : Other Documentation Manufacturer : Boeing Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe Qualification.Maintenance : Avionics Experience.Maintenance.Avionics : 15 Experience.Maintenance.Technician : 10

 

ASRS Report Number.Accession Number : 1295814 Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Confusion Human Factors : Training / Qualification Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Communication : Other Analyst CallbackBreakdown.Party2 : Completed

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Manuals Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 NOTE: This Maintenance report applies to all company DC-10 Aircraft, not just Aircraft X. The Pressure Regulating Shutoff Valve (PRSOV) and Overpressure Shutoff Valve (OPSOV) connections to all TRAS Lock Engine Duel Switcher valves are not connected properly. It has been verified via company Engineering that the PRSOV valve is actually connected to the Dual Switcher Valve OPSOV connection and the OPSOV valve is actually connected to the Dual Switcher Valve PRSOV connection. The connections are backwards. This is causing some Thrust Reversers to stow during Auto Re-Stow Testing in Maintenance. If the lines were properly connected, the Thrust Reverser Revers er would not be able to stow during testing. Flight Safety - It has always been my understanding that the OPSOV is solenoid controlled air to the Dual Switcher Valve. V alve. A company Engineer recently pointed out that engine air is actually at the Dual Switcher Valve anytime the engine is running. He showed me the [McDonnell-Douglas] LAMM schematic which shows the air flow to the Dual Switcher Valve with no solenoid control. The PRSOV valve could be open in flight as iitt is on the ground during the Auto Re-Stow test as a result of the lines being connected backwards. [Recommend] to properly connect the lines to the Dual Switcher Valve. Verify if the OPSOV air is still sti ll solenoid controlled air. If not, then we must connect the lines to the Dual Switcher Vavle properly. If the OPSOV is solenoid operated, then inform Engineering and change the LAMM [schematic] to reflect this.

Callback: 1 Reporter stated he has been working avionics and thrust reversers for over twenty-five years. The Thrust Reverser Actuation System (TRAS) and mechanical Locks are part of an FAA A.D. that also requires installation i nstallation and testing of a Dual Switcher Valve component on each GE CF6-80 series engines with connections for the Pressure Regulating Shutoff Valve

 

(PRSOV) and Overpressure Shutoff Valve (OPSOV) rigid pneumatic lines. The whole intent of the AD is to reduce the potential for reverser deployment in flight. Three requirements must be met to allow the PSROV air to be available for reverser movement. Reporter stated he believes the engine pneumatic lines to the Dual Switcher Valve were misrouted during the initial Switcher valve installation approximately several years ago. The pneumatic flow line from the OPSOV that should go to the OPSOV on the Dual Switcher Valve actually PSROV connection on the the Switcher Valve which have air flowing out, notgoes into to thethe Swi Switcher tcher Valve. As a result, pneumati pneumatic c air line should that should have been connected to the Switcher Valve for 'air flow to' the PRSOV was connected to the OPSOV port on the Switcher Valve. Pneumatic air pressure was/ is on the wrong side of the Switcher Valve. The Dual Switcher Valves have four lines. Three lines are input and one line for output. The Boeing LAMM schematic also shows air pressure at all times, but that is not correct, because there is a solenoid that actually interfaces and does not allow the PSROV to open unless unl ess the same three conditions are satis satisfied. fied. Reporter stated he would like to see two issues addressed. 1) switch the pneumatic lines at the Dual Switcher Valve to operate correctly. 2) Revise the Boeing LAMM schematic s chematic for the two pneumatic line connections to the Switcher Valve to prevent continued incorrect stowing of reversers during Auto-Re-Stow Testing of the Switcher Valve and reversers.

Synopsis An Aircraft Maintenance Technician (AMT) with extensive DC-10 Engine Reverser experience describes what he believes to be inaccurate Boeing Lamm schematics that have contributed to engine pneumatic lines being attached at incorrect positions on Dual Switcher Valves on GE-CF6-80 engines. The Switcher Valves are part of the FAAs Thrust Reverser Safety Enhancement System A.D.

 

ACN: 1295357

(12 of 50)

 

Time / Day Date : 201509

Place Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B767-200 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Records Complete : Y Maintenance Status.Released For Service : Y Maintenance Status.Required / Correct Doc On Board : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Installation

Component Aircraft Component : Wing Access Panel Aircraft Reference : X Problem : Improperly Operated

Person : 1 Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1295357

Person : 2 Reference : 2 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1295358

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation Material / Policy Anomaly.Deviation -- Procedural Procedural :: Published Maintenance

 

Detector.Person : Passenger Were Passengers Involved In Event : Y When Detected : In-flight Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 After arrival was informed by flight attendant that a passenger reported that an access panel on top of the left wing appeared to only have one fastener fast ener holding it on and that it was fluttering in flight. Upon further investigation it was found that 15 out of 17 screws were missing. Installed fasteners in panel and made a log entry.

Narrative: 2 This was the panel that is over the landing gear retract actuator 551CT. Panel was secured.

Synopsis Maintenance technicians reported that they were notified notifi ed of a loose wing panel after a passenger noticed it fluttering in flight. Several fasteners were found missing from the panel.

 

ACN: 1294332

(13 of 50)

 

Time / Day Date : 201506

Environment Work Environment Factor : Temperature - Extreme

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil Operating Under FAR Part.Other Mission : Ambulance Flight Phase : Parked

Component Aircraft Component : Power Drive System Aircraft Reference : X

Person : 1

Reference : 1 Location Of Person : Repair Facility Reporter Organization : Contracted Service Function.Maintenance : Technician Function.Maintenance : Inspector Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1294332 Human Factors : Situational Awareness Human Factors : Fatigue Human Factors : Time Pressure Human Factors : Workload

Person : 2 Reference : 2 Location Of Person : Repair Facility Reporter Organization : Contracted Service Function.Maintenance : Technician Function.Maintenance : Lead Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1294333 Human Factors : Workload Human Factors : Fatigue Human Factors : Situational Awareness Human Factors : Time Pressure

Person : 3

 

Reference : 3 Location Of Person : Repair Facility Reporter Organization : Contracted Service Function.Maintenance : Technician Function.Maintenance : Inspector Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Human Factors : Time Pressure Number : 1294670 Human Factors : Confusion Human Factors : Fatigue Human Factors : Situational Awareness Human Factors : Workload

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance Result.General : Maintenance Action

Assessments Contributing Factors / Situations Contributing Factors / Situations Contributing Factors / Situations Contributing Factors / Situations Primary Problem : Ambiguous

: : : :

Airport Weather Procedure Human Factors

Narrative: 1 I work in a 145 Repair station as a hangar mechanic, and I was asked to go to assist in a swashplate change on an AS350B3 that was stuck on the hospital landing pad due to a swashplate shim protruding from the center of the swashplate. swa shplate. The repair took 11 days. We had been working very long hours (10-14hrs daily) in very hot weather all outside on top of the Hospital pad where the helo was stranded. During the swashplate change after disassembly of the main gear box we noticed that the bolt holes had corrosion build up in them and the ring gear had also been corroding cor roding due to bad sealant on the bolt heads, so we ended up removing the entire assembly and changed out the epicyclic and housing at the same time. During the reassembly of the housing and epicyclic, (we had been working for 14 hours that day) we decided deci ded to call it and to get s some ome rest. I left to go to my hotel and came back in the morning to find that the epicyclic had already been installed into the housing, however, during my RII of the installation I noticed that the gearbox and epicyclic had been coated with Turco instead of mineral oil which is what is called out for. I notified the lead and he said they had installed i nstalled it after I left. So they ca came me up to the pad to confirm and ended up flushing the system out before we installed i nstalled the rest of the mast and components. The lead mechanic was instructing and helping to assemble the mast and swashplate assembly (the Maintenance Manual (MM) reference was printed out and we were going step by step). We had to take breaks often due to how hot it would get on top of the hospital but the job got finished. [Several months later] the helicopter was trucked in for a tail rotor strike. During a brief incoming inspection and cleaning another mechanic noticed that the dust cover and or boot that covers the top of the swashplate was missing.

 

  During our maintenance ops, there were many people constantly calling calli ng to figure out when we would be done which caused many distractions, so less or no phone calls during maintenance ops on an Aircraft on Ground (AOG) (AO G) aircraft would be iimmensely mmensely helpful. If the aircraft is stuck on the helipad or in an area where it cannot be moved to a hangar, putting up a temp shelter (roof tent) or something like that would help immensely with less fatigue and possible heat stroke, which in turn leads to more mistakes and less work time due to the time spent trying to cool down and regulate body temp and sunburn. pilot interaction during these maintenance ops would also help a lot, it makes our jobsNo as mechanics a lot harder when we not only onl y have supervisors and their bosses phoning us all the time to then have the pilot ask how much longer.

Narrative: 2 This aircraft was removed from service and placed under unscheduled maintenance for removable shims extruding from the swashplate on top of the hospital helipad. A [contract] was submitted for outside help as the maintenance crew on staff had not performed this job to a level of comfort. Maintenance Mai ntenance support arrived for assistance. Upon removal of the mast assembly, it was noted that the epicyclic gearbox and sun gear assembly were corroded beyond limits, further increasing i ncreasing the workload on the [roof] of the hospital in the middle of summer, requiring a full transmission replacement. Initially, we were told that removing the aircraft from the hospital by crane was not the best option at the time, as we were only to be performing p erforming a couple days' worth of work, but when th the e corrosion was found, it would have taken the same amount of time to reinstall everything needed to crane the aircraft as to t o put it back together to return to service. s ervice. The removal, disassembly, reassembly, and return to service took us 10 days of all mechanics working over 10 hours per day. During this time I worked work ed on and off with the mechanics performing the maintenance, as I am the lead mechanic for the program and had other priorities. During this 10 day event I called cal led a safety stand down day on day 7 as the maintenance crew was showing signs of heavy fatigue, both mentally and physically. The installation, ground runs, and check flights were completed and the aircraft was returned to revenue service. While I was not the primary pri mary mechanic on this job, I feel it necessary to submit this as I did help and did not notice the issue. [Over 2 months later] this aircraft was involved in a tail rotor strike at a scene call. This aircraft was loaded on a truck and shipped to a repair station for maintenance required for the tail rotor strike inspection. During acceptance inspection, it was noted that the swashplate appeared to be missing the dust cover on top of the swashpl swashplate. ate. I was notified by my supervisor, and began researching this issue. After consulting the removal and installation part numbers, it became apparent that the installed part number was not effective for this aircraft. After consulting the maintenance staff involved, and looking at the Illustrated Parts Catalog (IPC) for this install, we could not find the correct swashplate in the IPC, and the only part number shown was the one that was iinstalled. nstalled. The repair station has the aircraft at this time, and will make the repairs as necessary. This event was an eye opener to all of us as we look back to all of the long hours that were put in to get this aircraft back in service, and that sometimes we need to take a step back and look at ourselves before we look at the work ahead of us. In my opinion, there were multiple factors that lead to this incident. Maintenance staff was pressured, both personally and by the customer, to t o provide an expedited service that could not be met. Maintenance pressures were also felt from the heat during this time of the year, on top of an aluminum helipad, with no shade available avail able at the aircraft. The airframe IPC played a large role in the incorrect ordering of parts, as the IPC is somewhat vague when it comes to ordering parts for aircraft with different modifications installed

 

(i.e. dual hydraulics in this case). c ase). I believe this incident could have been avoided if the aircraft had been removed from the hospital from the very beginning, removing the pressures from the hospital on a direct level.

Narrative: 3 I was notified that an aircraft aircra ft had been sent by ground transport to the Repair Station due to a Tail Rotor strike. I was made aware that during the receiving inspection into the repair station that it was discovered that the Main Rotor Swashplate assembly was missing the top dust cover (boot). Later during this day it was also brought to my attention by the Lead Mechanic that after discussing this situation with Mechanic that was currently on duty that the Swashplate that is currently installed may be the incorrect assembly. Due to a previous recent event, the swashplate had been replaced. The replacement was due to a peel shim that was found during a preflight check that was pa partially rtially ejected from the top of the uniball. The work for this replacement r eplacement was [accomplished several months ago]. While attempting to order the replacement swashplate swashpl ate I was unable to find the replacement part number for this assembly in the online AS350B3 Illustrated Parts Catalog. I notified the lead mechanic to inform him that I was unable to find this part number. After some discussion we both agreed that the Airbus Helicopter Technical Representative should be called for support. I immediately called the Tech. Rep. and explained my situation and that this was to be installed on an AS350B3 with Dual Hydraulics. I was told that I would not find that part number in the AS350B3 IPC and that I would need the part numbers found on the Component Cards for the Rotating and Non-rotating Swashplates (sub-assembly part numbers) and that he would send me a sheet that th at would give a breakdown of these part numbers that would provide the Swashplate Assembly part number (Next Higher Assembly) that was needed. This Swashplate was ordered and properly received into the base. Before the work for the replacement of this Swashplate began, I voiced concerns with the Lead Mechanic that although I have performed this maintenance tasking before for a swashplate replacement on an AS350B3, it had been maybe as long as 6 years since the last time I had done this and I had not done this task on an AS350B3 with Dual Hydraulics. This coupled with the fact that this was a brand new base and that this maintenance was to be performed on the roof of the hospital with temperatures that were to be in the high 90's were also concerns that I voiced. The lead mechanic agreed that we would need additional support. He made arrangements to have a mechanic experienced at this procedure sent from another Repair Station Stati on and requested that I was to perf perform orm this as OJT that was to be documented in the OJT book provided to the field mechanics. Another experienced Mechanic was also sent for additional maintenance support. Although another mechanic signed off this installation, the three mechanics, myself included, involved in this installation shared equally the responsibility of this installation. I provided the RII and at that time I should have reviewed the installation procedure again with the two mechanics. I believe that each one of us were under the impression (although now knowing it to be wrong) that because the th e assembly that came off did not require the boot that this was still the case with new assembly that went on. I have reviewed the procedure in the AS350B3 Aircraft Ai rcraft Maintenance Manual (AMM) for the installation of the swashplate onto the Mast Assembly again and it does not distinguish between the different assembly types with either the required dust boot or a rain guard as is found on the AS350B3's with dual hydraulics. The procedure does call out for the installation of the boot and in retrospect I feel now that I should have questioned our installation at this time. There is also nothing that I could find on the hard cards that

 

distinguish the installation of the rain guard as opposed to the lip ring used for the installation of the dust boot. I feel the process for determining the part number for the Swashplate assembly is convoluted and not in good practice. I should have questioned this process at the time that I did not find the part number in the IPC. I believe there were more challenges with this swashplate change and eventually the Main Gearbox than normal in a field environment. This was a brand new base that was not completely equipped on yetthe to handle of heavy Thetofact work that was to be completed roof of this the type hospital wheremaintenance. the OAT was 95 100the degrees F each day and that we were on a metal helipad was extremely challenging. The teardown of the main gear box and Mast Assembly was completed in a small room on the rroof oof of the hospital just outside the elevator with no air conditioning or circulation of air. We worked 10 to 14 hours each day in order to t o reach our goals. Word w was as getting passed on to us about some of the outside pressures to have the aircraft back in service and that this was a new base and a new contract that was taken over and that this issues did not exist with them.

Synopsis Several Maintenance Technicians reported difficult working conditions that resulted in maintenance errors including the possible installation of the incorrect part number.

 

ACN: 1294072

(14 of 50)

 

Time / Day Date : 201509 Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : EMB ERJ 170/175 ER/LR Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Component Aircraft Component : Fan Blade Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1294072 Human Factors : Distraction Human Factors : Confusion Human Factors : Situational Awareness

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I removed and replaced number 20 and number 6 fan blades bl ades on left engine of aircraft, and I believe I may have put the wrong blade back into i nto the number 6 position. I had both new

 

and old blades in my box and might have mixed them up. I was speaking to another mechanic and possibly mixed up the blades. [I need] to double check and even triple check serial numbers off parts being installed.

Synopsis A maintenance technician described the conditions that contributed to the installation of an incorrect fan blade.

 

ACN: 1293413

(15 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : SA-227 AC Metro III Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Component : 1 Aircraft Component : Powerplant Fire Extinguishing Aircraft Reference : X Problem : Improperly Operated

Component : 2 Aircraft Component : Electrical Wiring & Connectors Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Taxi Function.Maintenance : Other / Unknown Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1293413 Human Factors : Situational Awareness Human Factors : Confusion Analyst Callback : Completed

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance When Detected : Routine Inspection Result.General : Maintenance Action

Assessments

 

Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Ambiguous

Narrative: 1 Maintenance personnel were instructed to [remove and replace] the #1 engine fire bottle that was due for scheduled maintenance. [The] acting lead mechanic called and stated that during the fire bottle change on the aircraft, power was applied and the fire bottle was discharged. Upon investigation it was found that the power and the ground wires on the fire bottle squib had been swapped and the squib was not wired properly. During investigation the mechanic performing the work stated that the wires were pre labeled but the following day when another fire bottle was installed i nstalled no labels were noted on the wires and a full run down of the wiring print had to take place prior to installing the replacement bottle. Mechanic was counseled on the need to label everything removed no matter how small it may be.

Callback: 1 The reporter confirmed that the fire bottle does not have a conventional connector for the squid. It has individual wires that are disconnected and reconnected independently.

Synopsis Maintenance Technician reported that when electrical power was reapplied following the routine replacement of a Metroliner engine fire extinguisher bottl e, the bottle was unexpectedly discharged. He revealed that wires had been incorrectly connected due to mislabeling of the wires.

 

ACN: 1292485

(16 of 50)

 

Time / Day Date : 201509

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Commercial Fixed Wing Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Parked

Component

Aircraft Component : Exterior Pax/Crew Door Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location In Aircraft : Door Area Cabin Activity : Boarding Reporter Organization : Air Carrier Function.Maintenance : Other / Unknown Function.Flight Attendant : Flight Attendant (On Duty) ASRS Report Number.Accession Number : 1292485 Human Factors : Communication Breakdown Human Factors : Troubleshooting Human Factors : Time Pressure Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : MEL Result.General : Release Refused / Aircraft Not Accepted

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1

 

I noticed the assist bottle at door d oor 1L lower than minimum recommendation. I then looked at all 4 doors which also were lower than required for aircraft airworthiness. I contacted the captain to contact mechanics and verify pressure on all doors. C/S (Customer Service) came onboard and asked if he could board. The Th e pilot, not putting two and two together said yes. I interjected and said sai d that they may have to fill door 1L and it was the only egress door available. The pilot agreed and we held boarding until mechanics coul could d verify pressure on all doors. Initially, the mechanic came onboard and began to tell me that it was not was my job - asthe he system, wrote ondismissed the release mechanic (whotake in my opinion not (onboard familiar with thelater). issue The (implying it would over 2 hours to fill all bottle bottl e - when I know in fact, it takes about 10 minutes for each bottle, by saying all doors were good). Something that is not only irresponsible, but criminal and his license should be suspended for dismissing some sensitive item and signing off on an item in which was not good to fly. At that time, the captain wi with th knowledge of aircraft maintenance, became intrigued as new to the Airbus (previous Boeing pilot). He asked me and I explained how the temperature gauge and the table all plays a part on determine which level each door bottle should be. He then grabbed his calculator and a flash light and proceeded to examine the door himself. He then looked at all 4 doors and agreed that they were below minimum. Since the mechanic at this time had already signed off as good to fly. The captain called maintenance mai ntenance and advised that they needed to bring him the table tabl e indicating the aircraft was good to t o fly. About 1/2 hour later, three mechanics came on board with the specifications on the doors. The pilots and mechanics discussed the gauge and soon it was clear that ALL 3 mechanics did not know how to read the gauge and were seeing pressure above of what it was - I have pictures. The pilot noticed that they could not agree, and drew a picture pic ture of the gauge and proceeded to explain how the mechanics were not reading the gauge accurately. They did not agree and left the aircraft. Not saying anything, when the captain inquire they did not respond. Later on, the captain called [operations] again and had to refuse the aircraft. ai rcraft. The mechanics never came back. A problem that could have been resolved in 1 hour was now over 105 minutes later. Pilot from the pilots' office came in and the captain captai n explained the problem. Later the captain asked the first officer to look l ook at the gauge and see if he would agree with wi th the needle marking. The first officer looked at the gauge and a nd also confirmed that in fact the needle was what it was told to the mechanics. Ops found us another plane. What transpired next is not only irresponsible but also criminal. By now C/S, and Ops had changed shift and this is the only thing I would say made they think the aircraft was air worthlessness. Ops scheduled the aircraft to fly to [another destination], now, mechanics had already signed off on the aircraft and done nothing else els e but disappearing. Customer Service w were ere new and they had no idea on what was going on. The captain told the new captain of the problem. But since we left, we can only hope the new pilot convinced the mechanics to fill the assist bottles. Later we checked and found out that the aircraft left. le ft. We did not know if it was fixed or left be. The negligence of these mechanics caused a chain reaction of failures that could cost someone's lives some day and for that reason all three should be reprimanded for their negligence and lack of knowledge on this aircraft.

Synopsis Mechanics and Captain disagreed about the gauge display for the exit doors' pneumatic charge. Different aircraft assigned.

 

ACN: 1291853

(17 of 50)

 

Time / Day Date : 201508

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B767-300 and 300 ER Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Cargo / Freight Flight Phase : Parked

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Maintenance : Inspector Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1291853 Human Factors : Confusion Human Factors : Training / Qualification

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I was assigned to work on aircraft to troubleshoot deferrals [Deferral No. 1] and [Deferral No. 2] per FIM 27-62-01. I attempted the operational test per AMM 27-62-00-715-002. This test failed. I then performed the B.I.T.E. of the SAC. This test has 2 levels one being the auto test, the other being the rig test. The rig test failed. At that point I re-deactivated the auto spoiler system as it was when the aircraft arrived. I was not aware of MIB 6-2715-08 which explains the rig test bite bi te of the SAC. Consequently the spoiler handle was restricted the spoiler handle movement to 50% travel. I had tested the spoiler handle operation prior to troubleshooting but neglected to do so after troubleshooting.

Synopsis

 

B767 Maintenance Technician was assigned the task of clearing a spoiler deferral, but was unable to do so. The MEL was reinstated, reins tated, but the spoiler handle was not tested and the aircraft was dispatched with the spoiler restricted to 50% of normal.

 

ACN: 1291474

(18 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 1201-1800

Place

Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Regional Jet 200 ER/LR (CRJ200) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Nav In Use : FMS Or FMC Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1 Aircraft Component : Engine Oil Seals Manufacturer : General Electric GE CF34-8 Aircraft Reference : X

Component : 2 Aircraft Component : Generator Drive Aircraft Reference : X Problem : Malfunctioning

Person : 1 Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1291474 Human Factors : Situational Awareness

 

Human Factors : Confusion Human Factors : Distraction Human Factors : Training / Qualification

Person : 2 Reference : 2 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1291475 Human Factors : Time Pressure Human Factors : Confusion Human Factors : Distraction Human Factors : Situational Awareness Human Factors : Workload

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : FAR Anomaly.Deviation - Procedural : Published / Policy Anomaly.Inflight Event / Encounter : Other /Material Unknown Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : In-flight Result.General : Maintenance Action Result.General : Flight Cancelled / Delayed Result.Flight Crew : Diverted

Assessments Contributing Factors / Situations : Contributing Factors / Situations : Contributing Factors / Situations : Contributing Factors / Situations : Contributing Factors / Situations : Primary Problem : Human Factors

Procedure Manuals Human Factors Environment - Non Weather Related Chart Or Publication

Narrative: 1 August 2015. In ZZZ, myself Aircraft Maintenance Technician (AMT X) and AMT Y, during a Service Check found a leak from the Integrated Drive Dri ve Generator (IDG) on the LeftLeft-hand hand Engine. While changing the IDG carbon seal, documents and references were misunderstood. The distractions inside the Hangar aided in misplacement of the O-Ring. The work interruptions from Management distracted us from the task at hand. We preformed the Leak Check and Operational Check and found everything to be within limits. Nothing seemed unusual and we signed off the aircraft. The following day, it was brought to our attention we had placed the O-Ring in the wrong place. While we were discussing this, the aircraft lost oil from the Left Engine and made an emergency landing. I would suggest more descriptive [maintenance] illustrations. A new Warning added to the Maintenance Manual, or internal document added. Availability to faster, more reliable access to manuals. Better training on (IDG) carbon seal replacement.

 

Narrative: 2 Aircraft Maintenance Technician (AMT X) and I (AMT Y), were installing a new carbon seal on the IDG on Engine One. During that process, we put a seal s eal in the wrong location. We misinterpreted the diagram depicting where the seal went. Throughout this process we had to keep going back to the [Maintenance] Manual to print out sub-tasks using usi ng computers that are exceptionally slow, as well as endure many interruptions/inquiries at the hands of Management which added to our distraction. After installation, we performed the Leak Check in accordance with the Maintenance Manual and there were no leaks so we did not realize our error at the time. ti me. During discussion about the project, Supervisi Supervision on found that we had incorrectly installed the O-Ring. By the time we discovered this fact it was the following day, (the mistake happened the day before). As A s the lines of communication to right this wrong had been opened, the aircraft lost the oil on the Left Engine most likely due to our mistake. The aircraft subsequently performed an emergency landing. It was easy to misinterpret misi nterpret the diagram in the Maintenance Manual. The iinterruptions nterruptions due to slow network access to the online Maintenance Manual and repeated Management interruptions added to the situation.

Synopsis After their CRJ-200 aircraft had departed, two Aircraft Maintenance Technicians realized they had installed a new carbon seal O-Ring at the wrong locati location on on # 1 Engine Integrated Drive Generator. # 1 Engine lost all oil in flight. Distracti Distraction, on, inadequate and easy to misinterpret maintenance diagrams, work interruptions i nterruptions from Management, lack of training and experience and a slow on-line Maintenance Manual program were noted as contributors.

 

ACN: 1290978

(19 of 5 50 0)

 

Time / Day Date : 201508 Local Time Of Day : 1801-2400

Place

Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Night

Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : Air Carrier Make Model Name : A320 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Takeoff Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Inspection Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1 Aircraft Component : Main Gear Manufacturer : Airbus Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Landing Gear Indicating System Manufacturer : Airbus Aircraft Reference : X Problem : Malfunctioning Problem : Improperly Operated

Person : 1 Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier

 

Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1290978 Human Factors : Workload Human Factors : Situational Awareness Human Factors : Distraction Human Factors : Communication Breakdown Human Factors : Time Pressure Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Person : 2 Reference : 2 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Lead Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe Experience.Maintenance.Lead Technician : 8 Experience.Maintenance.Technician : 13 ASRS Report Number.Accession Number : 1291033 Human Factors : Workload Human Factors : Communication Breakdown Human Factors : Time Pressure Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : MEL Anomaly.Deviation - Procedural : Maintenance Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action Result.General : Flight Cancelled / Delayed Result.Flight Crew : Returned To Departure Airport

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 A320 Aircraft has a recurring landing gear fault. This time the fault occurred in ZZZ1 and was made a Deferred Maintenance Item (DMI) in ZZZ1. Aircraft ferried to ZZZ with the landing gear lock down. Confirmed the aircraft was in the non-MEL configuration before starting work for the L/G not unlocked ECAM Message. The right landing gear retract actuator was ultimately removed and replaced. After all the operation checks were

 

completed and all cockpit indications were normal, cleared DMI for the Landing Gear Indication System. The aircraft took off from ZZZ ZZ Z and returned to the field for FLT F LT L/G Down indication after gear retraction. Aircraft restricted & advised to 235 knots ECAM message per flight crew and log book entry. After removing and replacing flight controls, landing gear components etc.. after inconvenient chronic or recurring faults, no Test flights are required by our Air Carrier. Inadvertently causing major anxiety and inconveniencing our paying passengers. Prior experience with other operators, a Test Flight would be required before the aircraft was returned to revenue flight.

Narrative: 2 Aircraft had multiple crew reports for the Right Main Landing Gear (MLG) not uplocked ECAM message upon gear retraction. The fault was worked in ZZZ2 and made a few flights, then the fault returned while the aircraft was in ZZZ1. The Landing Gear Indication System was deferred per the MEL by Maintenance team in ZZZ1. Request was made to the company to send the aircraft to our Maintenance facility in ZZZ3 for this repeat problem. They have the proper facility and tooling. Aircraft was Maintenance Ferried to ZZZ with the gear lock down only because we had jacks. jac ks. No facility and no tools for the job. We work in a Line environment on an un-level ramp and had to jack the aircraft high enough to preform gear swings and trouble shoot the Landing Landi ng Gear Retract System in an AOG situation on the flight line. Company sent a retract actuator, but the paperwork was incomplete. By the Second night we received loaner tooling from another Operator and a replacement actuator from Airbus which had paperwork issues as well. Late into the shift and after working multiple other aircraft, the paperwork issues were resolved and the actuator was released to maintenance to install. The right main landing gear retract actuator was removed and replace per the Trouble Shooting Manual (TSM) and Aircraft Maintenance Manual (AMM). All operational and leak checks and cockpit indications were normal with the aircraft on  jacks. The DMI was cleared by the replacement of the retract actuator. The aircraft took off from ZZZ on a revenue flight fli ght and the cockpit crew reported an ECAM Advisory Message FLT L/G DOWN indication after retraction and restricted advised to 235 knots. Crew returned to the field. Upon further trouble shooting found the L/G DOWN VMO/MMO selection switch (22FP) on the 188VU panel pan el in the aft E&E bay was inadvertently lleft eft in the L/G down position. Reset L/G DOWN VMO/MMO selection switch (22FP) to the L/G normal position. Messages cleared. Due to time constrains and pressure to return the AOG aircraft to service the (22FP) Switch was overlooked when clearing the DMI.

Synopsis Two Aircraft Maintenance Technicians reported recurring Right Main Landing Gear (MLG) L/G Not UNLOCKED ECAM faults on an A320 aircraft. Aircraft ferried to a Line Maintenance Station with limited resources. Right MLG Retract actuator replaced. No Flight Test required. Aircraft departed but returned to field with ECAM Advisory message FLT L/G DOWN. Found the L/G DOWN VMO (Maximum Operating Speed Limit)/MMO (Maximum Mach Operating Speed) selection switch (22FP) on the 188VU panel inadvertently left in the L/G down position. Reset switch to L/G 'Normal' position.

 

ACN: 1289759

(20 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 1201-1800

Place

Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Corporate Make Model Name : Citation Excel (C560XL) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Phase : Parked Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Inspection

Component : 1 Aircraft Component : Gear Up Lock Manufacturer : Cessna Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Main Gear Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Corporate Function.Maintenance : Technician ASRS Report Number.Accession Number : 1289759 Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance When Detected : Routine Inspection Result.General : Maintenance Action

 

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Chart Or Publication Primary Problem : Chart Or Publication

Narrative: 1 During Post Maintenance Checklist Technician foundseen Left-Hand MLG Hook with bushing. This is the third time i n a month in we have this issue. issu e. IUplock recalled when weworn did the Phase 1-4 inspections, [we did] a specific task to inspect the uplocks. I checked the Maintenance Manual and found Task XXXX001 Uplock Detailed Inspection is to be performed every 300-hours. I performed a search in i n [our] Maintenance/Inventory Tracking Program and the Approved Aircraft Inspection Program (AAIP) and cannot find the task anywhere. It is my belief that since si nce we have been doing the Phase-A and Phase-B Inspections that this task has been overlooked. Recommend that Task Card XXXX001 Uplock Detailed Inspection needs to be incorporated into some kind of scheduled maintenance event.

Synopsis An Aircraft Maintenance Technician reported finding a third Cessna CE-560XLS aircraft in a month with Main Landing Gear Uplock Hook bushings worn during du ring their Post Maintenance Checklist inspections. Technician believed that since si nce they have migrated from doing Phase 1-4 Inspections to performing Phase-A and Phase-B Inspections, the Uplock Detailed Inspection Task has been overlooked.

 

ACN: 1289753

(21 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737-800 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Ferry Flight Phase : Parked Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Inspection

Component Aircraft Component : Engine Driven Pump Manufacturer : GE/Snecma CFM-56 Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1289753 Human Factors : Communication Breakdown Human Factors : Time Pressure Human Factors : Workload Human Factors : Fatigue Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Other Communication Breakdown.Party2 : Maintenance

Events

 

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Staffing Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Equipment / Tooling Contributing Factors / Situations : Company Policy Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 August 2015. Began with an XA:00am morning flight from ZZZ4. [With departure] show time [eight hours] later. Aircraft arrived in ZZZ at XI:20. Sat in ZZZ for four hours then ferried B737 Aircraft X to ZZZ1 to replace another B737, Aircraft Y. Arrived in ZZZ1 early [the following morning]. A 20-hour and 40-minute day. We got to the hotel and I was finally able to sleep. After 6:30 hours of sleep, I received recei ved a phone call from Maintenance Control, "A mechanic mechani c is on his flight from ZZZ2, get out and start taking Aircraft Y apart so we can get this plane fixed". I got up, dressed, packed up and went down and had breakfast. I checked out of the hotel and went out to repair Aircraft Y. The mechanic and I got the plane fixed and ready for a late night departure. 15 hours and 35 minutes after my wake up. Approximately early afternoon it started to rain. rai n. It rained off and on for the rest of the day. After the repair was complete and an engine run for a leak check, the cowlings had to be closed. I laid under the engine to close the C-Cowls and Main engine cowling. Now I'm soaking wet from head to toe on my back. Wet ramp. We closed up everything, put the tools away, returned borrowed tools and I boarded the plane for a Ferry to ZZZ3. I changed my clothes in flight. A 6.5 hour flight from ZZZ, early morning arrival. I secured Aircraft Y and went to hotel. h otel. A 22 hour and 45 minute day. On arrival at the hotel that morning, I was told that our reservations were w ere for [the day before] and since we did not check in, our reservations were cancelled. The Crew rooms were re-booked, but mine was not. Since mine was not, I had no room. I had to wai waitt for a room to be available and cleaned before I could c ould get a room. Two hours llater ater I got a room. Three hours of sleep and I'm back out on Aircraft Y to do a Power Trim (PT) before we go to ZZZ4. A scheduled late afternoon departure. We were late. We left after midnight, the following day. On arrival in ZZZ4, I called the hotel and find out that my rreservation eservation was for the day before. Cancelled again. I called call ed Crew Scheduling and they re-booked my room at the Hotel ZZZ5. So I limo'd li mo'd to the hotel. I arrived late night. After two hours hour s of sleep, I woke up for my commercial flight home. I tried to check in i n on-line. There is a problem, I must call the airline. Once again my flight reservation was for the previous day, not the day later [which is what I was trying to fly]. It was cancelled. I had to pay a $50.00 re-booking fee. My flight was re-booked and I was on my way home. When the schedule changes, for whatever reason, the Crews Cr ews have someone there 24/7 to

 

change their itinerary. When Scheduler X is off, there is no one to change the Mechanics itinerary. They gladly do it, they just have to be told that there is a Mechanic with the crew. My first two 'Off' Days were wer e spent recuperating from a serious lack l ack of sleep the previous three days. This is a personal inconvenience because it interferes with my days off. 14days on the road plus two days resting means I'm working 16-days. But that is a personal inconvenience. If this had happened on Day-2 or -3 of a trip it would be a much muc h different story. When would a Mechanic have time to rest from this type of schedule? It doesn't happen often, but it does happen. Our schedules are much tighter than pilots pil ots and flight attendants. When there is a schedule change or broken airplane, if our Scheduler is not around to see that our itinerary is changed, it won't get changed unless we call them ourselves. Kind of hard to do when you have a Fuel Pump Package in your hands. It weighs 200 pounds. Please have someone inform Scheduling that if they re-book re- book the crews could they please ask about a mechanic. Just to see if maybe a Mechanic is affected by the schedule change too. It would be greatly appreciated by those that get these planes repaired. Thank you.

Synopsis An Aircraft Maintenance (AMT)long, working as anwork on-call Air ever Carrier Technical Representative describesTechnician his excessively irregular days, changing work hours, lack of adequate support for re-scheduling re- scheduling hotels and fatigue from lack of sl sleep. eep.

 

ACN: 1289750

(22 of 50)

 

Time / Day Date : 201508

Place Locale Reference.Airport : ZZZ.Airport State Reference : US

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737-900 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : N Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1 Aircraft Component : Fan Disc Manufacturer : GE/Snecma CFM-56 Aircraft Reference : X Problem : Improperly Operated

Component : 2 Aircraft Component : Fan Blade Manufacturer : GE/Snecma CFM-56 Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1289750 Human Factors : Workload Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance

 

Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Manuals Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Equipment / Tooling Primary Problem : Human Factors

Narrative: 1 While trying to remove N1 fan blade per given Aircraft Maintenance Manual (AMM), tool marks [were] made on [Fan] disk thus requiring unscheduled engine replacement. No exact tooling listed in given AMM to remove r emove N1 Fan blade shim/keeper weights and usi using ng hand to work is not really reall y possible. [Recommend] Tool [be] made or listed li sted [in AMM] to remove N1 Fan blade shim/keeper weights and added to AMM 72-21-02 and listed in required tool section. Also, [add maintenance] NOTE: given the importance on not having damage to Fan blade disk due to tooling marks.

Synopsis An Aircraft Maintenance Technician recommended a specific tool be made or listed in the Aircraft Maintenance Manual for technicians to use to avoid damage to CFM-56 Engine Fan disks when removing the N1 Fan Blade Shim/Keeper weights. Inadvertent tooling damage by Technician required unscheduled engine replacement on a B737-900 aircraft.

 

ACN: 1288221

(23 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 1801-2400

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng Operating Under FAR Part : Part 121 Mission.Other Flight Phase : Taxi

Person Reference : 1 Location Of Person : Company Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Maintenance : Lead Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1288221 Human Factors : Situational Awareness Human Factors : Distraction Human Factors : Time Pressure

Events Anomaly.ATC Issue : All Types Anomaly.Conflict : Ground Conflict, Less Severe Anomaly.Deviation - Procedural : Clearance Anomaly.Ground Excursion : Runway Anomaly.Ground Event / Encounter : Loss Of Aircraft Control Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Taxi Result.Flight Crew : Regained Aircraft Control

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1

 

After holding short at [runway], Control Tower told us that we were cleared to cross [runway] and expedite as there was another aircraft about to land. I started to advance engine throttles to expedite runway and saw aircraft getting closer to landing and I heard my taxi partner saying "go ahead, expedite". I thought we were in danger zone (middle of runway crossing it) and aircraft was ready for landing. There seemed to be a delay in the response of the aircraft to accelerate. ac celerate. We wanted to cross the runway a and nd clear the path for the aircraft to land (and avoid a collision). I lost control of the aircraft trying to clear the runway. Aircraft did not respond to the right turn, ending on the grassed area. It all happened very quickly and I found myself in the middle of an expedite situation si tuation that required immediate action. In an aircraft landing situation like this, it would have been different if the control tower instructed us to wait for the other aircraft to land instead of clearing us to cross runway and expedite. Another suggestion is to improve taxi/engine run-up training to include practice for expedite situation.

Synopsis A Maintenance Technician lost control of an aircraft following an expedited taxi across a runway with approaching landing traffic.

 

ACN: 1287823

(24 of 50)

 

Time / Day Date : 201508 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Airbus Industrie Undifferentiated or Other Model Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Deferred : Y Maintenance Status.Records Complete : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance

Component : 1 Aircraft Component : Data Transmission and Automatic Calling Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Tablet Manufacturer : IPAD Aircraft Reference : X Problem : Malfunctioning

Component : 3 Aircraft Component : Minimum Equipment List (MEL) Manufacturer : Airbus Aircraft Reference : X

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe

 

ASRS Report Number.Accession Number : 1287823 Human Factors : Human-Machine Interface Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Other Communication Breakdown.Party2 : Maintenance

Events

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : MEL Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action

Assessments Contributing Contributing Contributing Contributing

Factors Factors Factors Factors

/ / / /

Situations Situations Situations Situations

: : : :

Procedure MEL Human Factors Equipment / Tooling

Contributing Factors / Situations : Aircraft Primary Problem : Equipment / Tooling

Narrative: 1 August 2015, I was called onto an aircraft ai rcraft due to a 'Sys 2 Reg' fault. Deferred item through Lead and Maintenance Operations Control (MOC). Aircraft blocked out and I connected the MEL through IPAD/Digital communications under 'deferred Aircraft Maintenance Technician (remove from work)'. Upon arriving to work four days later, I was informed of the inadvertent fact [cl [clearing] earing] of the MEL. I explained the events that took place four days earlier to my Manager and senior Manager and came to the conclusion that there was an IPAD digital communication malfunction. I believe we can prevent this event from happening again by fixing the IPAD/Digital communications [software] issues. IPAD facted [cleared] MEL.

Synopsis An Aircraft Maintenance Technician recommended his Air Carrier fix the malfunctions with their IPAD/Digital communication software program that cleared a 'System-2 Regulator' fault discrepancy instead of deferring the Logbook item.

 

ACN: 1282992

(25 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft : 1 Reference : X Aircraft Operator : Air Carrier Make Model Name : B747-400 Operating Under FAR Part : Part 121 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Records Complete : N Maintenance Status.Released For Service : N Maintenance Status.Required / Correct Doc On Board : N Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Installation

Aircraft : 2 Reference : Y Aircraft Operator : Air Carrier Make Model Name : B747-400 Operating Under FAR Part : Part 121 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Installation

Component : 1 Aircraft Component : Circuit Breaker / Fuse / Thermocouple Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Fuel System Manufacturer : Boeing Aircraft Reference : X

Component : 3

 

Aircraft Component : Aircraft Documentation Manufacturer : Boeing Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1282992 Human Factors : Situational Awareness Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Analyst Callback : Attempted

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : MEL Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance When Detected.Other Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 We Cannibalized [Robbed] a GFI relay from Aircraft X, a B747-400, for Aircraft Y, another B747 without any trouble. After I had removed the relay from Aircraft Ai rcraft X, my Lead told me to install the unserviceable relay from Aircraft Y into Aircraft X so that they could defuel the plane. We recently updated to the GFI System to comply with an Airworthiness Directive (AD) that is due August 2015. I voiced my thoughts which were that we shouldn't install an unserviceable part of any kind into the system to which my Supervisor said to just do it so they can defuel the plane. After I refused to install it, i t, it was tasked to someone else who installed it and then the maintenance went undocumented, and they preceded to defuel the tank. It has since been removed and sent out for repair and still sti ll went undocumented that it was ever install installed ed on Aircraft X. This is a massive safety risk due to the GFI system is meant to disrupt power to the fuel pump in the case of a load imbalance, lost [electrical] phase, etc that could possibly cause for an ignition source inside the fuel pump, within the tank. My Lead claims its ok to do this because the plane is on the ground.

 

Synopsis An Aircraft Maintenance Technician Technicia n reported about a potential safety risk and iimproper mproper maintenance documentation practices after his Lead and Supervisor directed him to install a faulted and unserviceable GFI Relay into a B747-400 aircraft that needed to be defueled for maintenance. GFI was part of an airworthiness directive to disrupt electrical power to fuel pumps in a fuel tank.

 

ACN: 1282664

(26 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Regional Jet 200 ER/LR (CRJ200) Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Component Aircraft Component : Cowling/Nacelle Fasteners, Latches Aircraft Reference : X Problem : Design

Person : 1 Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Inspector Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1282664

Person : 2 Reference : 2 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1282996

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action Result.Flight Crew : Returned To Departure Airport

Assessments

 

Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Ambiguous

Narrative: 1 An A check was being performed and completed on the [next] morning. The aircraft had some remaining open discrepancies, so the aircraft ai rcraft was finished up and released on the [following] morning. Upon the aircraft leaving it had its RH engine upper nose cowl come loose and depart the aircraft. The mechanic working the engines that night had me take a look before closing to ensure all tools rags and equipment was removed. At that time I went back to the office offic e to complete my paperwork and paperwork/aircraft book closing responsibilities. Approximately 30-45 minutes later I went back out to do my walk around to see it closed up. I walked around to ensure all panels, latches, and cowls were cl closed osed up. Then I went on the staircase and took a peek up top to t o ensure the cowls were instal installed led and no tools and equipment were left on top of the aircraft. aircra ft. Then the aircraft got towed outside to complete ops checks and engine runs. The aircraft was towed back in after completion to check the engines for leaks. No leaks were noted, the lower core cowls were open then closed back up. I did a final walk past to ensure the core cowls have been closed. Viewing the upper cowls from the portable staircase provides a good visual to see that the cowls are installed. But not for a detailed visual check of fasteners. From that location the cowls appeared to be installed and had no obvious defect. Would need to do a detailed visual check of all al l the fasteners and not that just the cowls are installed.

Narrative: 2 I was working on the RH engine doing an inspection and servicing. Part of the task was to remove the upper and lower nose cowls. After performing all scheduled and unscheduled maintenance on the engine, I reinstalled both the upper and lower nose cowls as required. I reinstalled all of the required fasteners and then had the installation verified by an inspector. The aircraft did not leave until [2 days later]. Shortly after takeoff, the pilot had to shut down the RH engine and upon landing it was found that the upper nose cowl had departed the aircraft and the lower nose cowl was severely damaged as well as other area of the engine and tail. This part of the aircraft has a long history of failure. The FAA has issued an Airworthiness Directive (AD) to modify the nose cowls to strengthen and prevent these incidents from happening. This AD was performed on this aircraft and yet it still failed. I installed all of the hardware, which was verified and yet it still failed. I think that maybe there should be a more stringent verification process. Maybe after installing the nose cowls another mechanic or lead should verify the installation before going to the inspector. This would provide at least a third set of eyes before dispatching the aircraft. I know that this is what I will be doing, as well as maybe taking pictures of the installation.

Synopsis

 

A Maintenance Technician and Inspector describe desc ribe the events that led up to the loss of engine upper cowling from CRJ-200.

 

ACN: 1281886

(27 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B747-400 Operating Under FAR Part : Part 121 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Repair

Component Aircraft Component : Electrical Wiring & Connectors Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician ASRS Report Number.Accession Number : 1281886 Human Factors : Communication Breakdown Human Factors : Time Pressure Human Factors : Situational Awareness Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance Result.General : None Reported / Taken

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Primary Problem : Ambiguous

Narrative: 1

 

I was given an assignment to complete when I arrived for my work shi shift. ft. My lead asked me to look into [a specific] Non-Routine. I looked up the paperwork to repair the conduit as a s requested by my lead, and went out to inspect the extent of the damage. After I inspected ins pected the extent of the damage, I llet et my lead know that the conduit required replacement In Accordance With (IAW) the Boeing Standard Wiring Practices Manual (BSWPM). He told me it's okay just repair it, to which I refused to do because the manuals says that any damage MORE than 25 percent of the circumference requires replacement. He told me I just need to do it because the Li Line ne Maintenance Manager told him to get it repaired. At this point I handed my lead the paperwork and said I would not repair it, so I was put on another task. My lead proceeded to instruct one of our unlicensed unli censed mechanics to repair it by pl placing acing Teflon tape inside the conduit and filling it with red silicone and taping the outside of the conduit up. My lead annotated on the paperwork the following: 1) ASSESSED DAMAGE TO L/H BODY GEAR CONDUIT, FOUND TO MEET CONDITIONS FOR REPAIR AS DESCRIBED PER BSWPM 2) NO DAMAGE EXISTS TO WIRES OR CONVOLUTED TUBE AS DESCRIBED IAW BSWPM 3) REPAIRED METAL OVERBRAID WITH NO DEFECTS IAW BSWPM

Synopsis A Maintenance Technician disagreed with a Lead Technician on the use of an electrical conduit repair based upon the extent of the damage.

 

ACN: 1280088

(28 of 50)

 

Time / Day Date : 201504 Local Time Of Day : 1801-2400

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Work Environment Factor : Poor Lighting

Aircraft Reference : X Aircraft Operator : Fractional Make Model Name : Citation Excel (C560XL) Operating Under FAR Part : Part 135 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Installation

Component : 1 Aircraft Component : Speed (Rate Sensing) Aircraft Reference : X Problem : Design

Component : 2 Aircraft Component : Horizontal Stabilizer Control Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Contracted Service Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe Experience.Maintenance.Technician : 14 ASRS Report Number.Accession Number : 1280088 Human Factors : Training / Qualification Human Factors : Situational Awareness Human Factors : Confusion

Events

 

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance When Detected : Routine Inspection Result.General : Maintenance Action

Assessments

Contributing Factors / Situations : Manuals Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I replaced an airspeed switch for a stab mis-compare squawk. I performed an ops check of the two position horizontal stab system I/A/W CE560XL m/m chap. 27-40-00 and believed the system checked ok per the maintenance manual. [Seven weeks later] I was contacted by my supervisor and advised that the aircraft ai rcraft was in inspection and during the operational check of the horizontal stab system it i t was discovered that the airspeed swi switch tch failed the operational check and was installed incorrectly. After being made aware of this instance I was counseled on paying attention to the proper installation of components and indications during the operational checks. The company made a training PowerPoint for its employees to bring awareness to this issue and other components that can be installed incorrectly. Also a technical publication change request was submitted by Cessna from a request r equest made by QAC to note/warn of the possibility of this switch being able to be installed incorrectly. When I installed the switch and performed perfo rmed the ops check I believed it to check g good ood IAW the MM and would not have released the aircraft ai rcraft otherwise. I have learned to pa pay y closer attention to the components before and after install to try and assure this does not happen again.

Synopsis A Maintenance Technician was advised that the part he replaced several months earlier had been installed incorrectly. The fault was identified by the failure of the horizontal stabilizer operational check during routine inspection.

 

ACN: 1279377

(29 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : Learjet 35 Operating Under FAR Part : Part 135 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Maintenance Items Involved : Inspection

Component Aircraft Component : Turbine Engine Aircraft Reference : X

Person : 1 Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Taxi Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant Experience.Maintenance.Technician : 25 ASRS Report Number.Accession Number : 1279377 Human Factors : Communication Breakdown Human Factors : Situational Awareness Communication Breakdown.Party1 : Other Communication Breakdown.Party2 : Maintenance

Person : 2 Reference : 2 Location Of Person : Company Location In Aircraft : Flight Deck Reporter Organization : Air Taxi Function.Flight Crew : Captain Qualification.Flight Crew : Air Transport Pilot (ATP) Experience.Flight Crew.Total : 10000 Experience.Flight Crew.Last 90 Days : 70 Experience.Flight Crew.Type : 4000 ASRS Report Number.Accession Number : 1279356 Human Factors : Communication Breakdown

 

Human Factors : Situational Awareness Communication Breakdown.Party1 : Other Communication Breakdown.Party2 : Flight Crew

Person : 3 Reference : 3 Location Of Person : Hangar / Base Reporter Organization : Air Taxi Function.Maintenance : Other / Unknown Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant Qualification.Maintenance : Inspection Authority Experience.Maintenance.Inspector : 5 Experience.Maintenance.Technician : 16 ASRS Report Number.Accession Number : 1280087 Analyst Callback : Attempted

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance When Detected : In-flight Result.General : None Reported / Taken

Assessments Contributing Factors / Situations Contributing Factors / Situations Contributing Factors / Situations Contributing Factors / Situations Primary Problem : Ambiguous

: : : :

Procedure Logbook Entry Human Factors Company Policy

Narrative: 1 I had inadvertently returned a Learjet to service on many occasions with questionable inspection records for the T Piece Seal on an [engine]. The inspection record for this part was missing an inspector's stamp, but had been signed by the tech who had performed the inspection. I was alerted to the discrepancy by the overhaul facility and was later contacted by their vendor's FSDO. During our discussion, di scussion, the inspector and I came to the conclusion that the part had sufficient life remaining to make it to the next Major Periodic Inspection (MPI) Inspection because it had been inspected previously, before installation on another engine, and had sufficient life remaining until a new inspection would have been due if the part had stayed on the original engine. I called my operator's Principle Maintenance Inspector (PMI) for concurrence and it was concluded that the logic was sound and we could continue to fly the engine until the next MPI MP I Inspection was due. This afternoon, my operator's Director of Maintenance called me and to inform me that our Principle Operations Inspector (The previous previ ous PMI who had concurred with the vendors PM PMII had moved to another assignment) had questions about the airworthiness and documentation for this part. Together, the PMI and our Director Direc tor of Maintenance determined that the aircraft would be considered not airworthy. In my conversation with the Director of Maintenance, he said that our PMI had determined the week before that this discrepancy did not call in to question the airworthiness of the part. I could not

 

provide any documentation of the conversations with FAA inspectors from when this discrepancy had originally occurred. The FAA is not prepared to help us make a determination of the airworthiness of this part in any other way but to open an investigation.

Narrative: 2 I had inadvertently flown a Learjet on many occasions with questionable inspection records for the T Piece Seal on an [Engine]. The inspection record for this part was missing an inspector's stamp, but had been signed by the tech who had performed the inspection. I was alerted to the discrepancy by the overhaul facility, and was later contacted by their vendor's FSDO. During our discussion, the inspector and I came to the conclusion that the part had sufficient life remaining to make it to the next Major Periodic Inspection (MPI) Inspection because it had been inspected previously, before installation on another engine, and had sufficient life remaining until a new inspection would have been due if the part had stayed on the original engine. I called call ed my operator's Principle Maintenance Inspector (PMI) for concurrence and it i t was concluded that the logic was sound and we could continue to fly the engine until the next MPI Inspection was due. This afternoon, my operator's Director of Maintenance called me and to inform me that our Principle Operations Inspector (The previous PMI who had concurred with the vendors PMI had moved to another assignment) had questions about the airworthiness and documentation for this part. Together, the PMI and our Director of Maintenance determined that the aircraft would be considered not airworthy. ai rworthy. In my conversation with the Director of Maintenance, he said that our PMI had determined the week before that this discrepancy did not call in to question the airworthiness ai rworthiness of the part. I c could ould not provide any documentation of the conversations with FAA inspectors from when this discrepancy had originally occurred. The FAA is not prepared to help us make a determination of the airworthiness of this part in any other way but to open an investigation.

Narrative: 3 I am a Director of Maintenance for a Corporate Operator. I am self-disclosing an issue [discovered] during a review of the No. 1 engine log books, I discovered a lapse iin n documentation affecting the record keeping of the engine's compliance status. I conducted a fact finding mission that revealed the left engine had a part installed at its last overhaul Core Zone Inspection (CZI) that might have not been inspected properly. The issue had beendocuments reported to theconferring FAA, the manufacturer, and my employer. After a carefulwe review of the and with our FAA. Principal Pri ncipal Maintenance Inspector, agreed the manufacturer had determined the part was not due an Nondestructive N ondestructive Testing (NDT) inspection for another 1,700 hrs. and the next Major Periodic Inspection (MPI) inspection would be due 1,400 hrs. from the time the part was installed. However, the manufacturer decided to recommend the engine be removed from the aircraft and the part be NDT inspected in order to bring it in i n line with the rest of the part parts s that get the same NDT inspection during every CZI. This decision decisi on came in a letter of 'No Technical Objection'. That recommendation is what our current Principle Pri nciple Maintenance Inspector is relying on to determine if a compliance violation has occurred. Once I became aware of the lack of documentation in the aircraft records addressing the issue after Honeywell's recommendation, I grounded the aircraft for maintenance mai ntenance and am currently lining up a vendor that will support our aircraft to resolve the matter. The overhaul shop's records indicate the part was NDT inspected, but one internal tally sheet was missing an inspector's stamp. We were provided that sheet as well as another internal document where the mechanic wrote in his own cursive handwriting that he had

 

performed the inspection and an inspector stamped the document indicating i ndicating it had been complied with. We were also provided a Form 8130-3 releasing the part for airworthy status. That document is still in force and has not been rescinded to my knowledge. I believe the part was inspected and is airworthy ai rworthy but have decided to ground the aircraft to remove all doubt about the part's compliance.

Synopsis A Director of Maintenance and a pilot/mechanic pil ot/mechanic reported that they had been advised advi sed of a missed inspection signoff for an internal engine component, but that in discussion with a FAA Principal Maintenance Inspector, the part was airworthy with the time remaining. Later, the conclusion was questioned by another Principal Maintenance Inspector and was under investigation.

 

ACN: 1278743

(30 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 0001-0600

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Dawn

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737-900 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Person Reference : 1 Location Of Person : Company Reporter Organization : Air Carrier Function.Maintenance : Inspector Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1278743 Human Factors : Situational Awareness Human Factors : Time Pressure Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance When Detected : In-flight Result.General : None Reported / Taken

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Primary Problem : Human Factors

Narrative: 1

 

Aircraft supervisor approached me in my office and said he needed the inspector slot on log page for the #1 engine change signed for. I asked him if all the paper work was complete and the job was complete and his reply was yes and that the aircraft was at the terminal being loaded for its [next] trip. After I signed the log book I went to review the engine change paper work package when I discovered the Engine change installation i nstallation task was not completed. By the time this discovery took place the aircraft already [departed].

Synopsis

A Maintenance Inspector discovered that the Maintenance Supervisor was incorrect when he reported that all of the engine change paperwork was completed when he requested the final signoff.

 

ACN: 1278430

(31 of 5 50 0)

 

Time / Day Date : 201507 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Flight Conditions : VMC Light : Daylight

Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : Air Carrier Make Model Name : MD-82 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Initial Climb Airspace.Class B : ZZZ

Component Aircraft Component : Nose Gear Door Aircraft Reference : X Problem : Improperly Operated

Person : 1 Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1278430 Human Factors : Workload Human Factors : Distraction Human Factors : Time Pressure

Person : 2 Reference : 2 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Pilot Flying

 

Function.Flight Crew : Captain Qualification.Flight Crew : Air Transport Pilot (ATP) Experience.Flight Crew.Total : 18000 ASRS Report Number.Accession Number : 1278365 Human Factors : Time Pressure Human Factors : Distraction Human Factors : Workload Human Factors : Troubleshooting

Person : 3 Reference : 3 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : First Officer Function.Flight Crew : Pilot Not Flying Qualification.Flight Crew : Air Transport Pilot (ATP) ASRS Report Number.Accession Number : 1278685 Human Factors : Workload Human Factors : Time Pressure Human Factors : Distraction Human Factors : Troubleshooting

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action Result.Flight Crew : Took Evasive Action Result.Flight Crew : Returned To Departure Airport

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Primary Problem : Procedure

Narrative: 1 Called out to aircraft had ha d several items. Began with nose gear steeri steering ng problem, removed tow bar steering pin, opened gear doors, [the] other mechanic upstairs turned on hydraulic moved tiller, checked nose gear for proper operation, inspected tires wheels deflectors, all nose gear components, all checks good. Went upstairs to see if anything was felt on tiller became distracted with several interior items and forgot to close doors. Shorthanded, distracted with interior items trying to save boarding time. Needed to stay on job I started. No excuses. Made mistake trying to do too many tasks at once.

Narrative: 2

 

Upon gear retraction, the aircraft had a shudder throughout the plane. Gear handle was placed back down and shudder stopped. Accelerated to 200 knots and the shudder returned. Slowed to 170 knots for the remainder of the flight. fl ight. [Completed the QRH] and landed. Stopped straight ahead until the gear pins could be installed. Taxied to the gate.

Narrative: 3 We gave the flight attendants [a] briefing and notified Ops. We had a smooth landing and stopped straight ahead on the runway and waited for maintenance to pin the gear and proceeded to taxi to a gate.

Synopsis A distracted and overworked MD-82 Mechanic forgot to close the nose gear door following a maintenance procedure the previous evening. After takeoff the next morning a severe hydraulic system shudder during gear retraction caused the flight crew to lower the gear and return to the departure airport.

 

ACN: 1278065

(32 of 50)

 

Time / Day Date : 201504 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737 Undifferentiated or Other Model Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Records Complete : Y Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Testing

Component : 1 Aircraft Component : Indicating and Warning - Lighting Systems Manufacturer : Boeing Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Parking Brake Manufacturer : Boeing Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Maintenance : Technician Function.Maintenance : Lead Technician

 

Qualification.Maintenance : Airframe Qualification.Maintenance : Avionics Qualification.Maintenance : Inspection Authority Qualification.Maintenance : Powerplant Experience.Maintenance.Inspector : 34 Experience.Maintenance.Lead Technician : 1 Experience.Maintenance.Technician : 36 ASRS Report Number.Accession Number : 1278065 Human Factors : Situational Awareness Analyst Callback : Completed

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : In-flight Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Manuals Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Procedure Primary Problem : Human Factors

Narrative: 1 April 2015. [Company] Air Carrier B737 at ZZZ. Pilot reported that the "parking brake light illuminates intermittently at cruise (park brake handle -off)." Mechanic facted [closed] out the item with (replace parking brake light bulb). And then the item was dated, signed, and company employee number documented in Logbook. [Company] General Procedure Manual (GPM) XX-XX-2 Responsibility and Authority. The Mechanic that does the maintenance or repair must use the applicable technical data,  judgment, experience and knowledge to make a decision decision of airworthiness. [Company] General Procedure Manual (GPM) XX-XX-3. Responsibility for Maintenance Operations. Maintenance discrepancies that do not have a related manual procedure for repair will be repaired with sound maintenance practices in accordance with industry standards, experience, and good judgment and will have the applicable signature document with the complete description of the work done. The company compan y will not compromise aircraft sa safety fety for any reason. This includes flight schedules. Federal Air Regulations: 43.5 Approval for return to service after maintenance, preventive maintenance, rebuilding, or alteration. No person may approve for return to service any aircraft, airframe, aircraft engine, propeller, or appliance that has undergone maintenance, preventative maintenance, rebuilding, or alteration unless (a) The maintenance record entry required by 43.9 4 3.9 or 43.11, as appropriate, has been b een made;

 

43.7 Persons authorized to approve aircraft, airframes, aircraft engines, propellers, appliances, or component parts for return to service after maintenance, preventative maintenance, rebuilding, or alterations. (b) The holder of a mechanic certificate or an inspection authorization may approve an aircraft, airframe, aircraft engine, propeller, appliance, or component part for return to service as provided in Part 65 of this chapter. 43.9 Content, form, and disposition of maintenance, preventative maintenance, rebuilding, and alteration records (except inspections performed in accordance with Part 91, Parts 125, 135.411 (a) (1), and 135.419 of this chapter). (a) Maintenance record entries. Except as provided in paragraph (b) and (c) of this sections, each person who maintains, performs preventative maintenance, rebuilds, or alters an aircraft, airframe, aircraft engine, propeller, appliance, or component part shall make an entry in the maintenance record of that equipment containing the following foll owing information: (4) If the work performed on the aircraft, airframe, aircraft engine, propeller, appliance, or component part has been satisfactorily, the signature, certificate number, and kind of certificate held by the person approving the work. The signature constitutes the approval for return to service only for the work performed. perf ormed. 43.12 Maintenance records: Falsification, reproduction, or alteration. (a) may or make or cause false to be entry made: (1) No Anyperson fraudulent intentionally i n any record or report that is required to be in made, kept, or used to show compliance with wi th any requirement under this part.

Callback: 1 Reporter stated he initially thought the intermittent (flickering) Parking Brake Lamp might have been associated with an anti-skid valve issue. But, he had been around the B737s for years and suspected the lamp was failing. fai ling. So he changed the Parking Brake lamp and signed-off the Logbook item as 'Replaced'. He could not use an Aircraft Maintenance Manual (AMM) reference in the sign-off, because no procedure exists specifically for checking the light as functional. An FAA Inspector had been reviewing sign-offs and questioned the lack of a maintenance reference with the Logbook sign-off. In hindsight, perhaps he could have referenced their General Procedures Manual (GPM) in the Logbook, but he thought he had applied good judgment and sound maintenance practices as noted as acceptable sign-offs in their GPM; especially since the lamp was functioning just fine.

Synopsis An Aircraft Maintenance Technician (AMT) reports he did not include any Aircraft Maintenance Manual (AMM) reference in a logbook sign-off for replacement of a parking brake light on a B737 that had illuminated intermittently at cruise with the parking brake 'off.'

 

ACN: 1277957

(33 of 5 50 0)

 

Time / Day Date : 201506 Local Time Of Day : 0001-0600

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Night

Aircraft : 1 Reference : X Aircraft Operator : Air Carrier Make Model Name : B737-800 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Parked

Aircraft : 2 Reference : Y Aircraft Operator : Air Carrier Make Model Name : Commercial Fixed Wing Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked

Component : 1 Aircraft Component : Electrical Wiring & Connectors Aircraft Reference : X

Component : 2 Aircraft Component : Circuit Breaker / Fuse / Thermocouple Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person : Company Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1277957 Human Factors : Situational Awareness

 

Human Factors : Distraction Human Factors : Time Pressure

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance When Detected : Aircraft In Service At Gate Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I was tasked with [working several] aircraft with autothrottle inop, hgs (Heads-Up Guidance System) display inop, L2 window heat inop and engine control light write up along with the other regular task cards. While working on [aircraft X] I accomplished step 1 (battery replacement) and since there ther e was no part sent for the second step, I then went to work on [aircraft Y] with window heat and engine control light iissues. ssues. Meanwhile got notified that the part for the second step on [aircraft X] (battery charger) had showed up. Went back to the first plane to complete c omplete step 2 for battery charger change. During removal missed pulling one of the two circuit breakers both labeled battery charger. The charger cable terminal lug contacted and shorted damaging the contact terminal. Notified lead and supervisor of the issue immediately. Engineering desk was consulted and came to consensus to re-terminate a new contact lug or replace the run for that charger cable. There was a lot of work scheduled for the night. Parts were not all present at beginning of the shift. While working between the AOG (Aircraft on Ground) write ups for aircraft [X and Y] I missed pulling one of the breakers labeled battery charger.

Synopsis A Maintenance Technician neglected to fully remove power from the battery charger, resulting in shorting of the contact terminal that required replacement.

 

ACN: 1277063

(34 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B767-300 and 300 ER Operating Under FAR Part : Part 121 Flight Phase :Status.Maintenance Parked Maintenance Maintenance Status.Maintenance Maintenance Status.Maintenance Maintenance Status.Maintenance

Deferred : N Type : Unscheduled Maintenance Items Involved : Inspection Items Involved : Testing

Component : 1 Aircraft Component : Gear Extend/Retract Mechanism Manufacturer : Boeing Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Gear Lever/Selector Manufacturer : Boeing Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Hangar / Base Location In Aircraft.Other Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1277063 Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events

 

Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Anomaly.Inflight Event / Encounter : Other / Unknown Detector.Person : Flight Crew Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : In-flight Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Chart Or Publication Primary Problem : Human Factors

Narrative: 1 During inspection for a PIREP for a "grinding noise and feel" in the [Landing] gear handle after a Functional Check Flight (FCF) (previous PIREPs also), I found the landing gear control cables, in the forward cargo [pit] ceiling outboard side at approximately [frame] station 300, to be wrapped around each other. This was causing the stiff [gear] handle and grinding noise. Cables were inspected per Aircraft Maintenance Manual (AMM) and rerouted, re-rigged per AMM and all operational checks were normal. It appears that a floor beam repair had been accomplished recently, the cables removed during that process. [Contributing factor] Failure to properly inspect cable installation. [Recommend] proper [clearance] "clear to close" and inspection of routing of control cabl cables es when disconnected.

Synopsis An Aircraft Maintenance Technician (AMT) reports finding the landing gear control cables in the forward cargo pit ceiling wrapped around each other at approximately frame station 300 on a B767-300 aircraft. Pilots had made several previous write-ups for a stiff gear handle with a "grinding noise and feel." A floor fl oor beam repair had rec recently ently been accomplished that removed the cables. 'Clearance to Close' panels also an issue.

 

ACN: 1275197

(35 of 50)

 

Time / Day Date : 201507 Local Time Of Day : 0001-0600

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Type : Unscheduled Maintenance

Component Aircraft Component : Pax Seat Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1275197 Human Factors : Workload Human Factors : Troubleshooting Human Factors : Time Pressure

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance When Detected : Aircraft In Service At Gate Result.General : Flight Cancelled / Delayed Result.General : Maintenance Action

Assessments

 

Contributing Factors / Situations : Procedure Contributing Factors / Situations : Aircraft Primary Problem : Procedure

Narrative: 1 Wrong seats installed in Aircraft at the emergency exit row on both sides. The Th e Aircraft over wing escape had the wrong seats installed forward of the emergency exit. The tray table blocked the emergency exit and the seats in the emergency exit should have had tray tables in the arm rest they did not this was also the wrong seats installed at that row.

Synopsis An MD-80 had normal seats installed install ed in two of the emergency exit seat rows. T The he seatback tray tables could block the emergency exits.

 

ACN: 1274898

(36 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1801-2400

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : Regional Jet 900 (CRJ900) Crew Size.Number Of Crew : 2 Operating Flight Plan Under : IFR FAR Part : Part 121 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : Y Maintenance Status.Released For Service : Y Maintenance Status.Required / Correct Doc On Board : N Maintenance Status.Maintenance Type : Unscheduled Maintenance

Component : 1 Aircraft Component : Pneumatic System - Indicating and Warning Manufacturer : Bombardier CRJ Aircraft Reference : X Problem : Design Problem : Malfunctioning

Component : 2 Aircraft Component : Minimum Equipment List (MEL) Manufacturer : Bombardier CRJ Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant Experience.Maintenance.Technician : 40 ASRS Report Number.Accession Number : 1274898

 

Human Factors : Communication Breakdown Human Factors : Confusion Human Factors : Training / Qualification Human Factors : Time Pressure Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Analyst Callback : Completed

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : MEL Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : Aircraft In Service At Gate Result.General : Flight Cancelled / Delayed Result.General : Maintenance Action

Assessments Contributing Factors / Situations : MEL Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 When I [Maintenance Controller X] came on duty the L BLEED LEAK WARNING was being reported by phone by the flight crew. I called outstation Maintenance to come to the aircraft to try to find the cause of the indication. We checked the Maintenance Diagnostic Computer (MDC) for evidence and found none but ran a Bleed Leak Event Location test. The results of the test indicated a leak or false indication in the APU bleed air duct between the APU bulkhead and the Isolation Valve at the Crossover duct. The Mechanic inspected the duct and bleed [Overheat Warning] loops l oops and could not find any defects. We then ran the APU at the gate, supplying suppl ying air for a considerable length of ti time me and could not duplicate the fault. The aircraft was wa s released with no faults found. An hour or more later the warning came back. The Mechanic was still in the area so I had the crew shut down the APU and use an airstart to run the engines. My involvement ended at this point in the event because I became involved in some other problem. My comment to the Maintenance Operations and Duty Manager (MOD) at this point was that I suggested we fi find nd another aircraft for the flight because we could not effectively troubleshoot this "warning" problem without a 'break out box' and some other tooling and parts. I felt we were either proving a leak in the APU ducting or a false warning in that area at this point. The next thing I knew the APU was deferred and the aircraft was released. Maintenance Controller Z told me when I came cam e in for work the next week that he had been requested to submit a report because the deferral of the APU was deemed inappropriate. There was a lot of discussion discu ssion in the office between Maintenance Controller Z and the MOD as to the correctness of that and I am not sure where that w went. ent. I could not find an acceptable deferral for this fault. The deferrals stipulated that the APU Load Control Valve (LCV) had to function and in the warning condition, it is forced to 'close'; so in my opinion that is "not working".....This event transpired over several hours

 

and there was a lot of conversation in the office about how to move the aircraft. My solution was to replace the aircraft and send a roadtrip because I do not feel that outstation Maintenance can effectively troubleshoot a warning in this system without proper tooling and training. I guess I was overruled. I am submitting this ASRS report. My M y timeline is not firm and there w were ere a lot of other problems at the time. And guess what? I came in to work today and we have the same problem on the same aircraft again. The only difference is the location of the airc aircraft. raft. It is even showing the same locations again in the Anti-Ice Leak Detection Controller (AILC) event location test. Maybe we have a bad AILC? Or we have an actual leak that we have not located yet. There is a significant lack of knowledge of this system in the Maintenance Control office and "0" experience working on the system other than Maintenance Controller Y and myself. Nobody wants to hear what I have to say about it. I am too conservative and not deemed a "team player" when it comes to these kind of issues. It is my belief that any time a "warning" occurs in this system it appears to me that if the system cannot be deferred, it cannot be troubleshot effectively by an untrained, ill equipped outstation Mechanic "looking it over" and signing it off. If the system is not deferrable then it should demand a roadtrip supported by qualified mechanics with proper training and proper equipment and tooling.

Callback: 1 Reporter stated the "break-out box" is an interface tool that allows Maintenance to troubleshoot the Overheat Warning Detection (A and B) loops via the AILC Controller while outside of the very tight Avionics compartment on CRJ-900 aircraft. He believes that 90 % of the reliability issues at the gate involve false overheat warning EICAS messages caused by the loop sensing element connectors that use steel with ceramic insulators. The ceramic cerami c insulation is prone to cracking and will then bleed electrons, sending spurious, false warnings of a pneumatic leak through the Bleed Leak Detection System. The warning loops and connectors start in the Aft Equipment Bay and connect at the fuselage flat pressure bulkhead using 90-degree angle connectors and then run alongside the length of the fuselage APU duct, out to the wings, and engine pylons. Reporter stated that in the aircraft he reported about, two pneumatic leaks were eventually located at insulated duct clamps connecting the APU pneumatic duct manifold along theCRJ-900 internalrecently fuselagehad andthree the other leak was isolated in the Aft Equipment Bay. Another air returns caused by one of the Overheat Warning loop elements had made contact with a wing anti-ice duct.

Synopsis A Maintenance Controller reports about events surrounding an inappropriate deferral of an APU for an EICAS L BLEED LEAK WARNING on a CRJ-900 aircraft at an outstation gate. Controller also noted the significant lack of knowledge maintenance controllers have of the pneumatic system, the untrained, ill equipped outstation mechanics, and the lack lac k of effective troubleshooting the cause of the EICAS warning.

 

ACN: 1274892

(37 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : EMB ERJ 145 ER/LR Operating Under FAR Part : Part 121 Flight Phase :Status.Maintenance Parked Maintenance Deferred : Y Maintenance Status.Records Complete : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing

Component : 1 Aircraft Component : Fuel Crossfeed Manufacturer : Embraer Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Indicating and Warning - Fuel System Manufacturer : Embraer Aircraft Reference : X

Component : 3 Aircraft Component : Minimum Equipment List (MEL) Manufacturer : Embraer Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant

 

ASRS Report Number.Accession Number : 1274892 Human Factors : Confusion Human Factors : Situational Awareness Human Factors : Troubleshooting Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : MEL Detector.Person : Maintenance Were Passengers Involved In Event : N Result.General : Maintenance Action

Assessments Contributing Factors / Situations : MEL Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Procedure Primary Problem : Human Factors

Narrative: 1 On the evening shift ending, June 2015, an EMB-145 aircraft was in ZZZ with wi th a fuel system MEL (along with other items on the Bill Bil l of Work (BOW). The original squawk indicated that selecting the Fuel Transfer switch on the overhead panel to 'LOW' would supply fuel not only to engine selected, but also to that side's wing tank. Research indicated that this would happen selecting 'LOW' fuel in either direction. A thorough ops check for a lengthy period of time was performed, running APU and both engines trying to duplicate the squawk, trying all pumps and all combinations of switching. Completely unable to duplicate the squawk, I cleared the MEL. HOWEVER, in researching the squawk and MEL, I FAILED to completely review the Maintenance Procedures for MEL 28-XX-XX. As a result, I failed to properly completely "de-MEL" the fuel system. It came to my attention early this morning that the Defuel Valve was found safety wire closed, obviously in i n that configuration from the original MEL. Failure to completely research and review all the MEL procedures. In addition to researching a squawk, COMPLETELY review ALL MEL procedures related to that squawk if same has been MEL-ed.

Synopsis An Aircraft Maintenance Technician (AMT) was informed he had failed to completely review the Maintenance Procedures previously accomplished under MEL 28-XX-XX, when a Defueling Valve was found still safety wired closed after he had cleared the MEL. The deferral had noted when selecting the Fuel Transfer switch on the Overhead panel to 'LOW', fuel would be supplied not only to the engine selected, but also to that side's wing tank.

 

ACN: 1274216

(38 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil Operating Under FAR Part : Part 135 Mission.Other Flight Phase :Status.Maintenance Parked Maintenance Deferred : Y Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Work Cards Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Inspection

Component : 1 Aircraft Component : Turbine Engine Manufacturer : Turbomeca Arriel Aircraft Reference : X

Component : 2 Aircraft Component : Fuselage Manufacturer : Eurocopter Aircraft Reference : X

Component : 3 Aircraft Component : Aircraft Documentation Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Taxi Function.Maintenance : Lead Technician Function.Maintenance : Quality Assurance / Audit Qualification.Maintenance :: Inspection Qualification.Maintenance Airframe Authority Qualification.Maintenance : Powerplant

 

Experience.Maintenance.Lead Technician : 20 ASRS Report Number.Accession Number : 1274216 Human Factors : Workload Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Other / Unknown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Analyst Callback : Completed

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected.Other

Assessments Contributing Factors / Situations : Logbook Entry Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Primary Problem : Human Factors

Narrative: 1 An electronic news gathering helicopter was due [for] a 100-hour airframe plus several hourly engine inspections. Operations would not take the aircraft out of service due to another news helicopter being unavailable. It was decided dec ided to do the 100-hour in a manner that would allow the aircraft to be put back in service within 10 minutes if operations needed it. Upon reviewing the Work Order and Aircraft Ai rcraft Status Record, several inspection items were not completed, but on the status record were entered as completed. c ompleted. The work order form was lacking 'Inspector' signatures, the 'Instruction for Continued Airworthiness Inspections' were not signed off, and the Engine 100-hour and 750-hour 750- hour inspection items were not all completed. The log entry stated all al l inspections were done. The Engine manufacturer's inspection requires a 100-hour 100- hour Engine Health Inspection. This was not completed and not signed-off on the inspection form. The aircraft ai rcraft was returned to service servi ce without a complete inspection in accordance with the manufacture's recommendations. The aircraft is operated under Part 135 and a log statement requires the aircraft to be maintained In Accordance With (IAW) FAR Part 91.409.F.3.; the manufacturer's recommended inspection program. This was not accomplished. The Repair Station procedures for completing a Work Order and a Return to Service (RTS) llog og entry were not followed. Consequences: aircraft placed back in service with overdue inspection items.

Callback: 1 Reporter stated one of the engines of a twin engine prop aircraft had plowed into one of the two news helicopters on the ramp, resulting in his company's AS-350 Eurocopter's being contracted for use as a dual purpose news gathering helicopter. Five Technicians had been assigned to perform a portion of the 100-Hour Inspection in order to accommodate the on-call demand, whenever the AS-350 was to be needed. Reporter stated he had reviewed the Work Order and Aircraft Status Record the following

 

day as a Quality Assurance (QA) Lead Technician for the 100-Hour and 750-Hour Inspections and noticed the incomplete paperwork, inspections not completed but signedsi gnedoff, incorrect log entries and the Repair Station procedures for completing a Work Order and a Return to Service (RTS) log entry were not followed. He notified the Director of Maintenance (DOM) about the release of their AS-350 Eurocopter with required maintenance and inspections not completed, but response from his DOM was not supportive of his concerns.

Synopsis A Quality Assurance (QA) Lead Technician reports about one of their AS-350 Eurocopter's that was placed back in service with overdue Airframe and Powerplant 100-Hour and 700Hour inspection items not completed. His company operations had contracted with a news gathering organization to provide an AS-350 on short notice. He notified his Director of Maintenance (DOM) about the non-compliance, but the response was not very supportive of his concerns.

 

ACN: 1274075

(39 of 50)

 

Time / Day Date : 201506

Place Locale Reference.Airport : ZZZ.Airport State Reference : US

Environment Light : Night

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B757-300 Operating Under FAR Part : Part 121 Flight Phase : Parked Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Maintenance Status.Maintenance Status.Maintenance Items Items Involved Involved :: Testing Work Cards

Component : 1 Aircraft Component : Indicating and Warning - Air Conditioning and Press. Manufacturer : Boeing Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Air Conditioning and Pressurizaton Probes & Sensors Manufacturer : Boeing Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : General Seating Area Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1274075 Human Factors : Communication Breakdown Human Factors : Troubleshooting Human Factors : Other / Unknown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events

 

Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected.Other

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Equipment / Tooling Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 I was assigned four airplanes: airp lanes: A, B, C, D and a crew consisting of nine people, plenty to accomplish the work required for that night. ni ght. I was working under the direction of Lead Mechanic X, he wanted to address a specific item in Aircraft D that a previous Lead wasn't comfortable performing. He [Lead Mechanic X] wanted to get people trained in performing the Job Card, as he requested four specific sp ecific people of his choice to perform the jjob, ob, at which I added two more people very proficient; all other aircraft maintenance was done without incident. However, Aircraft D had some difficulties, we didn't have the right equipment and no parts to replace the part if it failed, (Altitude Pressure switch). Management assumed we had the parts and equipment to finish fini sh the job. We removed the Pressure switch and started to test, [Altitude] Pressure switch failed, then we moved to the test of the EPR and found out the equipment was registering a leak which we couldn't find the source. The Supervisor determined the technicians technici ans weren't operating the equipment correctly and ordered us to put everything back and he would cancel the job cards, which he did. Then we ran the th e engine and found an EICAS message that won't [go] [ go] away. Also, the Fuel Governor was leaking l eaking at a rate of 16 dro drops ps per minute. Supervisor contacted Technical support and advised us that message wasn't a big deal, it eventually would go away. I didn't feel comfortable stopping the test in the middle of the work and putting all that we took apart back without finding out if the Pressure switch was ok, or if we had an EPR leak, or if the EICAS message and fuel leak was related to we [us] disturbing the system. We should have finished the test and found out either the system was operating satisfactorily, or if not, what corrective action we needed.

Synopsis An Aircraft Maintenance Technician (AMT) reports not feeling comfortable with an order from their Maintenance Supervisor to stop all testing and reassemble all the items they had taken apart after an Altitude Pressure switch had failed and an EPR leak was discovered on a B757-300 aircraft. The supervisor canceled the Job Cards and noted the technicians involved were not operating equipment correctly. Replacement for a failed Altitude Pressure switch was not available.

 

ACN: 1273178

(40 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B767-300 and 300 ER Crew Size.Number Of Crew : 2 Operating Flight Plan Under : NoneFAR Part : Part 121 Flight Phase : Parked Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Work Cards Maintenance Status.Maintenance Items Involved : Inspection

Component : 1 Aircraft Component : APU Aircraft Reference : X

Component : 2 Aircraft Component : Oil Tank Aircraft Reference : X

Component : 3 Aircraft Component : Other Documentation

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1273178 Human Factors : Confusion Human Factors :Breakdown.Party1 Communication Breakdown Communication : Maintenance

 

Communication Breakdown.Party2 : Maintenance Analyst Callback : Attempted

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person Maintenance Were Passengers: Involved In Event : N When Detected : Aircraft In Service At Gate Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Manuals Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Chart Or Publication Primary Problem : Human Factors

Narrative: 1 On day-shift, around noon, I was assigned oil service on this aircraft with an [Aircraft Maintenance Manual (AMM) Chapter] 12-79-01 [for servicing]. Per the [task] card, I [made] 'Not Applicable' (NA'd) the APU [Task card] steps, as there was no message on EICAS [to service]. I was not assigned an ETOPS check, nor was the aircraft within in a three-hour ETOPS window at that time. My assignment was not part of an ETOPS check (at airport ZZZ, we are assigned to service every wide-body within one hour of arrival, regardless regardl ess of destination) and I checked the EICAS page, there was no APU OIL QTY message. I also noticed the aircraft was listed as Out of Service (OTS) in our web based system. Later in the day, I observed a crew working the same plane on an ETOPS departure, and no one had physically checked the APU sight-glass. We suddenly realized this was a gotcha, and mechanics were assigned to complete the APU sight-glass on a second 12-79-01 [Servicing card]. Had this conversation not occurred, all agreed this aircraft would have departed out of compli compliance ance with the ETOPS requirements. [Recommend to] examine the specific items/ETOPS cards and resolve the possibility of the APU NOT being physically checked and how to avoid non-compliances and/or FAA Letter of Investigation (LOI). The NA is simply too easily missed.

Synopsis A Line Aircraft Maintenance Technician (AMT) reports how a standard task card procedure to check APU oils on their wide bodied aircraft within one hour of ar arrival rival by using the EICAS page to determine if oil servicing was necessary, did not satisfy the requirement to visually check the APU oil sight-glass for ETOPS flights. The B767-300 was originally scheduled Out of Service (OTS), but later had an ETOPS flight scheduled.

 

ACN: 1272208

(41 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1801-2400

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Dusk

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : MD-82 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : Y Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance

Component Aircraft Component : Communication Systems Aircraft Reference : X

Person Reference : 1 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1272208 Human Factors : Time Pressure Human Factors : Workload Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Communication Breakdown.Party2 : Flight Crew

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Ground Event / Encounter : Other / Unknown Detector.Person : Maintenance

Assessments

 

Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Contributing Factors / Situations : Staffing Primary Problem : Human Factors

Narrative: 1 Rampthe wasdelay closed dueI told to weather. Thethe ramp tower at ZZZdue c called alled us and .wanted to know what was. tol d the Agent, ramp is closed to weather weather. About 10 minutes later the ramp was open, but hand signals only. We could not do a manual [engine] [ engine] start without communicating with both the [flight] crew and the Mechanic on the engine without a headset. The Lead Mechanic in charge did not want to send at least three people for a Manual start; instead [we] only had two people. When you're getting hand signals from the [flight] crew you can't see the Aircraft Maintenance Technician (AMT) on the engine to signal [a] Start, Stop or Abort. And he, the AMT on the engine, can't see anyone in the front of the aircraft getting signals from the FLT crew; and the flight crew has no idea on what hand signals to use also, because there is no set of guidelines for this. [Contributors were] a lack of safety concerns for employees and the aircraft. Having a system in place and a policy on doing a Manual start with and without a headset to communicate with the flight deck and the AMT manually starting the engine. If you're using hand signals, how many people should we use and where are they positioned at and can you even use hand signals to do a Manual start? Also, how to address an emergency during a manual start with just hand signals. Then put this in a training bulletin.

Synopsis A Line Aircraft Maintenance Technician (AMT) describes his frustration and safety concerns surrounding a manual engine start procedure on the ramp with limited personnel and having to use hand signals without a standard set of guidelines for everyone to follow. Headsets could not be connected to the MD-82 aircraft due to weather conditions.

 

ACN: 1272205

(42 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : Jet Ranger All Series Undifferentiated or Other Model Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 135 Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Records Complete : N Maintenance Status.Released For Service : Y Maintenance Status.Required / Correct Doc On Board : N Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing

Component : 1 Aircraft Component : Powerplant Fuel Control Unit Manufacturer : Allison Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Engine Indications Manufacturer : Allison Aircraft Reference : X Problem : Malfunctioning

Component : 3 Aircraft Component : Aircraft Logbook(s) Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization :: Technician Air Taxi Function.Maintenance Qualification.Maintenance : Inspection Authority

 

Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1272205 Human Factors : Situational Awareness Human Factors : Confusion Human Factors : Communication Breakdown Analyst Callback : Completed

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : In-flight Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Logbook Entry Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Aircraft

Narrative: 1 June 2015, late afternoon; the pilot called me (approximately 80 miles from base) and advised he had a 'FADEC Degraded' light illuminate in-flight. I asked him to power up the aircraft and tell me if there was still a FADEC light. He said there was. I then asked him to move the throttle to idle. He did and told me that the FADEC light went out. Knowing what I know of the FADEC system, I knew that this thi s indicated there were no current faults iin n the system. I then asked him to do a ground run and call me back when he was done. He called me back and advised that the run-up was fine and that there were no FADEC lights. I asked him to power up the aircraft airc raft one more time to double-check that there were no more FADEC lights. He did this thi s and there were no lights. At this point I was not sure what I could do to the aircraft so I advised him to fly it home. This has been an ongoing intermittent problem since May 2015. We have replaced nearly nearl y every component in the whole system. An Avionics Technician spent a couple days going through wiring and was unable to find anything wrong. After speaking with my supervisor, (actually a Maintenance Manager), over the incident, he informed me I should have not allowed the aircraft to fly since I had not visually inspected it in accordance with a mai maintenance ntenance manual. He is probably right, I wasn't sure what to look at that I hadn't al already. ready. This has been a repeating problem that has been unable to be duplicated in the hangar. The FADEC Manufacturer Technician Representative has been contacted many times & we have followed all his advice. The aircraft would usually be in service for up to 10 days and fly 6 or 7 hours without any trouble. In my opinion, this intermittent problem has moved way beyond the scope of a Field Base Mechanic & the aircraft should have been flown to a Service Center where major disassembly or re-wiring can occur. The bottom line is that I probably should have driven up to the aircraft, looked at it, and made the proper logbook entries (even if the discrepancy could c ould not be duplicated) before I allowed the pilot to fly it home.

Callback: 1

 

Reporter stated the 'FADEC Degraded' light means the FADEC System was still controlling the Rolls Royce-250 Engine, but had lost some of its functionality. The problem with trying to troubleshoot and isolate the cause for the light l ight illuminating was, the fault only occurs every ten to twelve hours; and only in flight. The FADEC Manufacturer's Technical Representative continued to believe the intermittent fault was caused by a wire chafing somewhere. Reporter stated his company finally sent the helicopter to a Service Center and the FADEC Representative had a large wire bundle bundl e harness removed. A Technician laid the removed wire bundle down on a table, inspected each wire wi re and found two wires that had chafed through a small area of wire wi re insulation that had been contacting each other, but not consistently. The wire bundle was replaced and so far, no other faults have occurred.

Synopsis An Aircraft Maintenance Technician (AMT) was informed by a company pilot that one of their Bell BHT-407 helicopters had a 'FADEC Degraded' light illuminate in flight. The intermittent fault would occur every ten to twelve hours and had been an on-going problem for months that could not be duplicated in the hangar.

 

ACN: 1272196

(43 of 50)

 

Time / Day Date : 201506

Place Locale Reference.Airport : ZZZ.Airport State Reference : US

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B777-200 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Mission : Passenger Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Cards Maintenance Status.Maintenance Status.Maintenance Items Items Involved Involved :: Work Installation Maintenance Status.Maintenance Items Involved : Inspection

Component Aircraft Component : Oxygen System/Pax Manufacturer : Boeing Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : General Seating Area Reporter Organization :: Technician Air Carrier Function.Maintenance Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1272196 Human Factors : Communication Breakdown Human Factors : Confusion Human Factors : Training / Qualification Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Analyst Callback : Attempted

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected.Other

 

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Chart Or Publication Contributing Factors / Situations : Aircraft Primary Problem : Chart Or Publication

Narrative: 1 While working an Engineering Repair Authorization EC/EA and AD 2012-11-09, Step 2-B1 appears to have the mechanic inspect the existing cable, install the mask and insert [Release] Cable pin into i nto the striker pin of the cylinder if no damage was found. There was a misunderstanding by the [maintenance] crew of Step 2 of AD 2012-1 2012-11-09, 1-09, since the mechanic had to install a new cable, which is not addressed in AD 2012-11-09. As a result, the Cable assembly and oxygen masks were incorrectly installed on a B777-200 Aircraft during reactivation of the Oxygen System. Additional reference should include an Illustrated Parts Catalog (IPC) 35-21-01-40b (item C) for a better understanding of [Release] Cable routing. Also add a [maintenance] step to install any missing cable to [passenger [pass enger O2] box, including hardware, into the Engineering Kit for AD 2012-11-09 and better training.

Synopsis An Aircraft Maintenance Technician (AMT) recommends an additional reference be added to Airworthiness Directive (AD) 2012-11-09 to include Illustrated Parts Catalog (IPC) 3521-01-40b, (item C). The IPC would provide a better understanding of the Passenger O2 mask box release cable routing. Misunderstanding of Step 2 of the AD resulted in an incorrect installation of the release cable and O2 masks on a B777-200 aircraft.

 

ACN: 1271618

(44 of 50)

 

Time / Day Date : 201506

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737 Undifferentiated or Other Model M odel Operating Under FAR Part : Part 121 Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1 Aircraft Component : Weather Radar Aircraft Reference : X Problem : Improperly Operated

Component : 2 Aircraft Component : Throttle/Power Level Manufacturer : Boeing Aircraft Reference : X Problem : Improperly Operated

Component : 3 Aircraft Component : Circuit Breaker / Fuse / Thermocouple Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Maintenance : Technician ASRS Report Number.Accession Number : 1271618 Human Factors : Situational Awareness Human Factors : Training / Qualification Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events

 

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Chart Or Publication Contributing Factors / Situations : Procedure Contributing Factors / Situations : Manuals Primary Problem : Human Factors

Narrative: 1 Found weather radar 'On' and running in the hangar. Per reference [Aircraft Mai Maintenance ntenance Manual (AMM)] 34-43-00-040 Procedure it states, do not move the thrust lever. The movement of the thrust lever can cause automatic operation of the Predictive Windshear System. This can cause injury i njury to persons and damage to equipment in the area of the nose radome. We need documentation to protect workers from this health hazard. Pulling Radar [Circuit Breaker C/B] should be required before maintenance is performed. Most are not aware of this hazard.

Synopsis An Aircraft Maintenance Technician (AMT) reports finding a B737 weather radar unit 'On' and running in the hangar during aircraft maintenance. Technician noted the need for documentation to protect workers from the health hazards of radar rada r operations should also include pulling the Radar Circuit Breaker (C/B) before maintenance is performed.

 

ACN: 1270807

(45 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft : 1 Reference : X Aircraft Operator : Government Make Model Name : Large Transport Operating Under FAR Part : Part 91 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Testing

Aircraft : 2 Reference : Y Aircraft Operator : Government Make Model Name : Medium Transport Operating Under FAR Part : Part 91 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1 Aircraft Component : Pitot-Static System Aircraft Reference : X

Component : 2 Aircraft Component : Nose Gear Door Manufacturer : Lockheed Aircraft Reference : X Problem : Malfunctioning

 

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Contracted Service Function.Maintenance : Inspector Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe Qualification.Maintenance : Inspection Authority Experience.Maintenance.Inspector : 15 Experience.Maintenance.Lead Technician : 14 Experience.Maintenance.Technician : 18 ASRS Report Number.Accession Number : 1270807 Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Analyst Callback : Completed

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance Were Passengers Involved In Event : N When Detected : Routine Inspection Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 I have a [Maintenance] Manager, Manager X, X , who continually attempts to cover up discrepancies with the aircraft we have at ZZZ Flight Facility. Before I left for a [special assignment], I wrote a discrepancy which whi ch downed [one of our engine turboprop] aircraft, that had both nose landing gear doors out of rig. While I was [away], I was told that the issue was resolved and that the door system was re-rigged. Upon my return I was walking by the aircraft and noticed that it was still out of rig, I then approached Manager X about it and questioned him. He asked me if we could not write the discrepancy up in the [Maintenance Tracking Computer System]; and to fix it when we were working on a different discrepancy. I refused to do that. I wrote it up in the [Maintenance Tracking System]. Manager X was visually vis ually upset at me for this. He then confronted me and told me I was wrong to write it i t up. I showed Manager X in i n the Maintenance Manual in which it gives him instruction on how to properly perform the maintenance; mai ntenance; he said he followed the instructions as they were written. I asked him a few key points to the rigging and explained to him why it was wrong. He said he could see my point but he still did not want to go back to the [Agency] and tell them that he had done it incorrectly because it would make him look bad. I told him that I could fix it correctly and that we need to do it right. He agreed and then I re-rigged the doors.

 

Another instance Manager X had pressured me to perform a modification to an aircraft system we have. One of our [aircraft] was in ZZZ2, I was sent out to install an additional pitot probe, I had sent out the tools and required requi red parts to perform the modification, I had a drawing to follow that our Engineer had developed and approved. The Scientist whose instrument it was, asked for me to make a major change to it. I informed the scientist that I would have to get him in contact with our engineers to make the proper installation drawing for me to follow and it would have to pass analysis. I al also so called Manager X and filled him in on the matter. Manager X instructed me to have the scientist make pen and ink changes on the drawing and to just do it. I informed him that I was not comfortable making changes to a drawing without approval or an analysis done to it. After arguing with me and trying to convince me that it would be OK and that my Airframe/Powerpla Airframe/Powerplant nt (A/P) license would not be on the line, he finally gave up. I have numerous cases about Manager Xs misjudgments mi sjudgments and creating a work environment where he wants to cut corners. I have listed a few and will give one more example. I was in ZZZZ for another assignment this year and we had an issue with our [for engine turboprop] aircraft. Aircraft Maintenance Technician and myself, troubleshot the discrepancy: (#4 engine would not start). start) . We discovered the engine to have tw two o bad ignitor leads. The solution was easily easil y apparent, replace both ignitor leads, the old ones were clearly unusable, one was arcing through the shielding and the other was broken in half at the ignitor. I called Manager Manag er X to notify him that w we e would require new ignitor leads to continue our science missions. He then tried to convince me to just use one ignitor lead, off of another engine that was on the airplane. airpl ane. That would have had two engines with one [good] ignitor lead each. The Exciter Box which whi ch supplies ignition power to the engine, would have more than likely arced onto the closest possible item it could have to expel its energy. A likely and close item [for that arc] could have been a fuel heater strainer and could have resulted in a catastrophic disaster. I once again had to tell him that I was uncomfortable with that type of maintenance. We installed the correct corre ct parts and were able to continue our science missions safely. These are a few examples of his managerial decisions that affect us and the safety of our customers. I submit these to you worrying about what he has confronted other mechanics with; has he convinced them to perform unsafe maintenance?

Callback: 1 Reporter stated that he and his Technician work partner were recently fired after notifying the same Manager about several other aircraft discrepancies that required maintenance prior to departure. Ironically, he (Reporter) noted he had helped the Manager get the Maintenance Manager position.

Synopsis An Aircraft Maintenance Technician (AMT) reports about his Maintenance Manager who continually attempts to cover up discrepancies with the aircraft they have at their Flight Facility. Technician also includes i ncludes examples of the same Manager applying pressure to perform maintenance or modifications to their aircraft, not in compliance with their Practices and Procedures Manuals.

 

ACN: 1270752

(46 of 50)

 

Time / Day Date : 201301 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US

Environment Light : Daylight

Aircraft Reference : X Make Model Name : No Aircraft Maintenance Status.Maintenance Type : Scheduled Maintenance

Component : 1 Aircraft Component : Turbine Engine Manufacturer : Rolls Royce

Component : 2 Aircraft Component : Other Documentation Manufacturer : Rolls Royce

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Inspector Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1270752 Human Factors : Situational Awareness Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance Were Passengers Involved In Event : N Result.General : Maintenance Action

Assessments

 

Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Equipment / Tooling Primary Problem : Human Factors

Narrative: 1 Since [a few years ago], I have used on occasion a company issued LED Black light, Inspecting Roycewas engine components have been recently informed that No EngineeringRolls Variance issued for the useand of these Lights.

Synopsis An Aircraft Maintenance Inspector reports using LED Ultraviolet type lights for Fluorescent Penetrant Inspection (FPI) of Rolls Roll s Royce Engine parts for more than two years, believing beli eving an Engineering Variance had been issued to allow the use of the LED lights.

 

ACN: 1270457

(47 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 0601-1200

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B757-200 Operating Under FAR Part : Part 121 Mission : Cargo / Freight Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Installation

Component Aircraft Component : Pilot Seat Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person : Gate / Ramp / Line Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe Experience.Maintenance.Technician : 30 ASRS Report Number.Accession Number : 1270457 Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance Analyst Callback : Completed

Events

 

Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : Aircraft In Service At Gate Result.General : Maintenance Action Result.General : Flight Cancelled / Delayed

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Chart Or Publication Contributing Factors / Situations : Aircraft Primary Problem : Chart Or Publication

Narrative: 1 Company B757-200 aircraft. Captain seat track lock assembly faulty. Potential exists for a pilot to loose control and wreck an airplane on approach when the seat shifts unexpectedly. [I am] requesting a directive requiring increased scruntiny of this critical mechanism on B757/B767 fleets. This is an unrecognized safety critical cri tical issue. I replaced the seat assembly June 2015. A Routine Inspection Task card for the seat assembly is in use and I suspect this is not enough to prevent future accidents. In this example, the Captain found the problem and made a log entry.

Callback: 1 Reporter stated many of the B757s and pilot seats are 25 to 30 years old. He does doesn't n't know when, or if a seat overhaul is required, but he believes the segmented checks on their B757s only require a yearly inspection for seat operation and condition. He found both tension springs broken under the Captain's seat for the Track Lock Control lever. The lock lever overcomes the spring tension in order to release r elease the pin that locks the seat in i n the seat tracks. The springs were not a line replaceable item. With both springs broken, the Track Lock Control lever did not have a positive tension to secure the seat's latching pin in the seat's floor tracks. As a result, he could easily make the seat slide forward or aft merely by shifting his weight in the seat. Reporter believes the minimal maintenance checks for flight fli ght crew seats are not adequate to maintain seat serviceability. That's why reporter was requesting a fleet wide campaign to check flight crew seats on B757/B767s. Reporter wants to be clear that the seat design is not the issue, just the limited maintenance checks of the seats, which do not seem to be adequate.

Synopsis A Line Aircraft Maintenance Technician (AMT) reports about an unrecognized critical safety issue that exists for pilots to lose control of B757/B767 aircraft on approach, if the pilot seat shifts unexpectedly due to broken Seat Track Lock Control assemblies. Technician suspects the routine seat inspection task card is not sufficient to maintain adequate serviceability of crew seats.

 

ACN: 1270323

(48 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 0001-0600

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B737-800 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Parked Flight Phase : Taxi

Person : 1 Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Other / Unknown Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1270323 Human Factors : Confusion Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Troubleshooting Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Person : 2 Reference : 2 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Other / Unknown Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1270324 Human Factors : Communication Breakdown Human Factors : Distraction Human Factors : Workload Human Factors : Situational Awareness

Communication Breakdown.Party1 : Maintenance

 

Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Maintenance

Person : 3 Reference : 3 Location Of Person : Gate / Ramp / Line Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant Experience.Maintenance.Lead Technician : 7 Experience.Maintenance.Technician : 15 ASRS Report Number.Accession Number : 1275231

Person : 4 Reference : 4 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Captain Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Air Transport Pilot (ATP) ASRS Report Number.Accession Number : 1272572 Human Factors : Communication Breakdown Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : MEL Anomaly.Deviation - Procedural : FAR Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : Taxi Result.General : Maintenance Action Result.General : Flight Cancelled / Delayed Result.Flight Crew : Returned To Gate

Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 The crew from [aircraft X] called over the aircraft radio enroute to ZZZ1. They said that his Blue Overhead Fuel Valve light was illuminated. i lluminated. I asked if the engine was sti still ll running, they said yes. I asked if the engine was operating within normal parameters, they said

yes. I asked if there was any engine fluctuation, they said no. I told him that it appeared

 

to be an indication issue. The crew agreed and continued the flight to ZZZ1. I completed a Turnover Report in the Maintenance Mai ntenance Control turnover log that the Overhead Blue Engine valve light was illuminated. Upon landing in ZZZ1, the [flight] crew created a discrepancy that it was the Spar Valve light that had illuminated in flight. Iilluminating. had believed that theofcrew was discussing that it was the Engine Valvethere lightwould that was Because this belief, I had even discussed wi th with the crew be a possibility MEL'ing valve in ZZZ1. I turned this information over to the on-coming Maintenance Control shift. The aircraft Engine Valve was MEL'd in ZZZ1 by the on-coming shift. The aircraft flew to t o ZZZ2 where company Maintenance determined that the MEL ma may y have been incorrectly applied. ZZZ2 Maintenance corrected the Spar valve problem and cleared the Engine Valve MEL. ZZZ2 Maintenance Mai ntenance noted that the discrepancy and the resolution did not balance. My belief had been that the crew had been seeing an Engine Valve fault. I turned this information over to the on-coming shift. The crew wrote that they had a Spar Val Valve ve fault. The on-coming shift used my turnover report to apply an MEL that may have not been correct. ZZZ2 Maintenance replaced the Spar valve and cleared the Engine valve MEL. Ensure that discrepancies and resolutions balance.

Narrative: 2 Aircraft had pilot report (P/R) inbound to ZZZ1 for # 2 Eng Spar valve Blue light illum in flight. I contacted ZZZ1 Maintenance & told Tech we would MEL the light. Tech read me the log page but I did not hear him say it was the Spar valve the crew had written wri tten up. I instructed the tech to accomplish the procedures for the MEL I wanted to apply 73 73-10. -10. Tech accomplished them. There was a communication problem with which c/b needed to be pulled & collared and the location of it. i t. The MEL for the "Eng. valve light" # 73-10" was completed. Initially I had the tech collar the incorrect breaker which was rectified later. After the acft arrived in ZZZ2 the techs called ZZZ Maintenance Control and informed them of the error. At start of shift, received [Turnover] tie-in that "Eng. valve light ill illum um bright." My first thought was a Cowl Anti-Ice light was on. My co-worker told me to look again at the tie-in and I read that it was a Eng. valve lt. I pulled up the MEL for that light (not uncommon for it to occur) and contacted the tech in ZZZ1. After the acft landed the tech read the P/R to me. I missed the tech telling me it i t was the Spar valve & not the Eng valve. I proceeded to have the tech MEL the Eng valve as stated above. We had a discussion while filling fi lling out the book about circuit breaker (C/B) location. l ocation. At that time I had the tech c collar ollar the wrong breaker at my direction. This error was discovered later & amended to the correct c/b for that MEL. While Tech in ZZZ1 was accomplishing the MEL I was answering calls from other techs & helping with a window heat in ZZZ3 & in ZZZ4 with a piece of debris in a panel in front of the elevator. Techs in ZZZ2 trouble shot/s & repaired the system originally written up. Reversed the MEL procedures & removed the MEL. I didn't look at the log page picture the Tech sent from ZZZ1 till the next day on my way to work. I make it a priority to look at them as soon as possible. Maintenance Mai ntenance Controller. Evening [shift]. Workplace interruptions during task.

Narrative: 3

 

Technician Y was assigned to do company B737-800 aircraft [inbound] flight [into ZZZ1]. Upon arrival of aircraft at gate, there was in inbound write-up for # 2 Engine valve light illuminated. I, Technician X, was then called upon by Technician Y to perfom MEL 73-10 Maintenance Procedure for # 2 Engine, [because] he was not qualified to do engine runup. After completing MEL 73-10 procedure with no faults, I then turned it over to Technici Technician an Y who was in direct contact with ZZZ Maintenance Controller X to close out the resolution description block MEL procedures applied. After back fromfor gate, was called on our with Maintenance cell [phone], that the aircraft aircraft was was pushed returning to gate no I 'engine start'. Upon arrival to gate, I found that the wrong Circuit Breaker (C/B) was pulled and collared. It was determined after the fact that information and guidance by ZZZ Maintenance Control that the MEL to pull and collar the C/B was for another MEL procedure. I then proceeded to correct the issue and a nd pulled and collared the proper C/B per the MEL 73-10.

Narrative: 4 Maintenance performed MEL on Fuel Spar issue, MEL improper applied. Maintenance applied wrong procedure to Fuel Spar MEL, engine did not start.

Synopsis Two Maintenance Controllers, an Aircraft Maintenance Technician (AMT) and a Captain describe their involvement with a reported # 2 Engine Fuel Spar Valve Overhead Blue light fault that was miscommunicated and deferred as an Engine Valve Blue fault light on a B737-800 aircraft. A downline Maintenance Station noted that the original discrepancy and the resolution did not match. Spar valve was replaced and Engine Valve MEL cleared.

 

ACN: 1270315

(49 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1801-2400

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Dusk

Aircraft Reference : X Aircraft Operator : Air Carrier Make Model Name : B777 Undifferentiated or Other Model M odel Operating Under FAR Part : Part 121 Maintenance Maintenance Maintenance Maintenance Maintenance Maintenance

Status.Maintenance Deferred : N Status.Released For Service : Y Status.Maintenance Type : Scheduled Maintenance Status.Maintenance Items Involved : Work Cards Status.Maintenance Items Involved : Testing Status.Maintenance Items Involved : Installation

Component Aircraft Component : Main Gear Door Manufacturer : Boeing Aircraft Reference : X

Person : 1 Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Carrier Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1270315 Human Factors : Workload Human Factors : Distraction Human Factors : Communication Breakdown Human Factors : Situational Awareness Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Maintenance

Person : 2 Reference 2 Location Of: Person.Aircraft :X

Location In Aircraft : Flight Deck

 

Reporter Organization : Air Carrier Function.Flight Crew : Captain Function.Flight Crew : Pilot Not Flying Qualification.Flight Crew : Air Transport Pilot (ATP) Experience.Flight Crew.Total : 23000 Experience.Flight Crew.Last 90 Days : 113 Experience.Flight Crew.Type : 5300 ASRS Report Number.Accession Number : 1269899

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : FAR Anomaly.Ground Event / Encounter : FOD Detector.Person : Air Traffic Control Were Passengers Involved In Event : N When Detected : In-flight Result.General : None Reported / Taken

Assessments Contributing / Tooling Contributing Factors Factors // Situations Situations :: Equipment Staffing Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I was assigned to work the Center Axle Inspection on a B777. I used a long wooden 2"x4" as a tool to align the truck with the inner cylinder on the LH Main Landing Gear (MLG). When we achieved alignment, at approximately late morning, I placed the tool on the outer lip of the main landing gear wheel well door. We then proceeded to reassemble the LH main landing gear center axle. Later that evening I was performing Brake Operational checks in the cockpit with the Inspector. When the checks were complete, the mechanic on the ground began to service the Center system hydraulic fluid. I was observing the quantity in the cockpit and asked the mechanic on the ground to close the landing gear doors so we would have an accurate accu rate quantity reading. When we finished the fluid service, servic e, I went to the ground, completed the Job Card and began to clear away the remaining tooling and equipment so the aircraft could be taken t aken out of the hangar. Apparently, the tool was still on the door when the door was closed and fell out of the wheel well when the aircraft went on a flight the next day. Aircraft/Cabin potential damage caused By FOD. [Recommendations]: 1) The tool should not have been placed on the door. 2) The door should have been cleared better before it was closed. 3) The tool was an old, dirty di rty 2x4, brown and black in color. A bri brightly ghtly painted board would be easier to see. 4) Only two mechanics were assigned assi gned to finish this job which iincluded ncluded down jacking the aircraft, removing the jacks, servicing the landing gear struts and transitioning the aircraft from Air Mode to Ground Mode.

Narrative: 2

 

Just after takeoff Tower said another aircraft reported that something fell from our aircraft. We asked them to let us know what they found. No negative indications from aircraft instrumentation. No negative flight control effects. We asked Flight attendants if they noticed abnormal noise or sights - nothing. It was reported that airport ops found a 2x4 on the runway. We consulted Maintenance, determined nothing amiss and continued to destination.

Synopsis An Aircraft Maintenance Technician (AMT) reports placing a 2" x 4" board against the outer lip of the Left Main Landing Gear (MLG) door after completing a Center Axle alignment on a B777 aircraft. MLG door was closed later, but the 2X4 fell out of the wheel well after takeoff also told from the perspective of the Captain Cap tain of the flight. Distractions, workload and limited staffing were contributors.

 

ACN: 1269736

(50 of 50)

 

Time / Day Date : 201506 Local Time Of Day : 1201-1800

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Light : Daylight

Aircraft Reference : X Aircraft Operator : Air Taxi Make Model Name : Bell Helicopter Textron Undifferentiated or Other Model Operating Under FAR Part : Part 135 Flight Phase : Parked Maintenance Status.Maintenance Deferred : N Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Installation Maintenance Status.Maintenance Items Involved : Inspection Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1 Aircraft Component : Fuel Tank Manufacturer : Bell Helicopters Aircraft Reference : X

Component : 2 Aircraft Component : Fuel Booster Pump Manufacturer : Bell Aircraft Reference : X

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : Air Taxi Function.Maintenance : Technician Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant ASRS Report Number.Accession Number : 1269736 Human Factors : Situational Awareness Human Factors : Time Pressure Human Factors :Breakdown.Party1 Communication Breakdown Communication : Maintenance

Communication Breakdown.Party2 : Maintenance

 

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance When Detected : Aircraft In Service At Gate Result.General : Maintenance Action

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Environment - Non Weather Related Primary Problem : Human Factors

Narrative: 1 1/4" Drive 7/16" Shallow Socket unaccounted for during FWD Fuel Cell replacement FAA Alert Service Bulletin (ASB) compliance. Socket used to Torque (TQ) Fuel transfer lines inside fuel bladders. Last believed used to TQ Boost Pump and Transfer Pump housing. Discovered missing after Aircraft was fueled for Return to Service. Barrels for waste fuel were full from initial defuel. Aircraft was scheduled for training flights early evening. Thorough search of the facility and aircraft was initiated. Decision was made to enter a discrepancy of missing socket. Entries included inspection of critical areas that would effect safety of flight, ie. Engine Air Intake, Intake Plenum, Engine Deck, Transmission Deck, Flight Control Vertical Tunnel, Flight Controls and Rotating Members. Trash cans that were used throughout duration of ASB compliance were emptied that afternoon. The existing existi ng trash cans were sorted through. thr ough. Given more time, arrangements to empty the waste fuel barrels and defuel the aircraft to inspect Fuel Bladders would have been the next course of action. Training Flight crew was notified of situation and actions taken. Decision was made to accept the aircraft for service. Lack of assertiveness. [Recommendations:] Travel box with tool control. Tool verification verifi cation at the end of each working day. Tras Trash h collection should be done after completion of work.

Synopsis An Aircraft Maintenance Technician (AMT) reports about the efforts made to locate a 1/4" inch drive, 7/16" inch shallow socket that was unaccounted for after a Forward (FWD) Fuel Cell replacement on a Bell BHT-407 helicopter. Inspections of critical areas that would effect safety of flight were accomplished; socket not found. Fuel tanks were not drained. Training Flight crew accepted aircraft for service.