ASRS Database Report Set - Maintenance Reports

ASRS Database Report Set

Maintenance Reports

Report Set Description .........................................A sampling of reports from aircraft maintenance personnel.

Update Number ....................................................30.0

Date of Update .....................................................January 31, 2017

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

Ames Research Center 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 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 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 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.

Report Synopses

ACN: 1403720 (1 of 50)

Synopsis A Lead Technician reported that when called out to check the Main Landing Gear wheel on

an A320, due to high brake temperature, found it unserviceable after the ground crew released the aircraft calling the wheel okay.

ACN: 1403322 (2 of 50)

Synopsis A Maintenance Support person reported that temporary repair procedures for the B767-

300F main cargo door seal depressors comes from different sources and are inconsistent, and the tracking of these repairs is not standard.

ACN: 1400115 (3 of 50)

Synopsis Maintenance Supervisor reported technicians found a large non standard toaster was used directly beneath an outlet area while working on an aircraft. The heat generated tripped

the Ground Fault Interrupter (GFI) and melted the plastic panel above the toaster.

ACN: 1398810 (4 of 50)

Synopsis A Maintenance Inspector reported that some Ram Air Turbines (RAT) are not properly stowed, when this occurs the RAT is unable to deploy.

ACN: 1398441 (5 of 50)

Synopsis A Maintenance Technician reported that During Track and balance on a EC-135 Helicopter,

a Main Rotor blade was needed. Upgraded the existing blade per a Service Bulletin.

ACN: 1397957 (6 of 50)

Synopsis A Technician on an Airbus A319 reported that tray tables are mounted on the backs of seats in an emergency exit row.

ACN: 1397700 (7 of 50)

Synopsis Maintenance Personnel reported that when lowering the flaps on a B737 the flaps

contacted the roof of a golf cart.

ACN: 1397179 (8 of 50)

Synopsis A maintenance person reported that Airbus seats are being used in Boeing aircraft which

makes it difficult locating parts.

ACN: 1394256 (9 of 50)

Synopsis Mechanic reported failing to verify that the cotter pin in the nuts when inspecting the main

servo flight control input rods on a Eurocopter AS350. One of the nuts was safetied with a

cotter pin and the other was safetied with diaper pins.

ACN: 1394255 (10 of 50)

Synopsis Mechanic reported he forgot to safety the input oil line to fitting on the main transmission

on a Eurocopter AS350.

ACN: 1394006 (11 of 50)

Synopsis A Mechanic reported while in the process of getting authorization to defer a Crew Rest Area door on a B777, a Supervisor became irate and removed him from the assignment.

ACN: 1391027 (12 of 50)

Synopsis Several mechanics reported that a BHT-407 Helicopter aft tail rotor gear box fairing had an

undocumented hole added to access the gear box oil level site gage.

ACN: 1388975 (13 of 50)

Synopsis Aircraft Inspector reported while accomplishing a routine inspection he missed an extra washer that was installed on an elevator tab control rod.

ACN: 1386725 (14 of 50)

Synopsis A Maintenance Technician reported finding a piece of 2x4 in a B787 reverser that caused

damage to a cascade vane and an L Duct section.

ACN: 1386256 (15 of 50)

Synopsis

Several mechanics reported that when pushing back a Boeing 777 the TTWS (Tow Team

Warning System) did not function and the aircraft's RH wing tip struck the RH elevator of another aircraft.

ACN: 1383504 (16 of 50)

Synopsis A Mechanic reported that a British Aerospace HS-125-800 had a fuel leak from the APU

Fuel Control and it was not contained in the in the APU Containment Box.

ACN: 1382155 (17 of 50)

Synopsis A B737NG Mechanic reported he was unable to determine the position of a nose cowl anti-

ice valve in order to defer the valve in the closed position.

ACN: 1381760 (18 of 50)

Synopsis Maintenance Technician reported that while attempting to stow a Ram Air Turbine (RAT) on an ERJ-170, the blades were misaligned causing damage to the blades and the aircraft.

ACN: 1380702 (19 of 50)

Synopsis A Lead Technician reported that the iron content in the oil system of the engine in a

Eurocopter AS350B2 was beyond factory recommended specifications.

ACN: 1380317 (20 of 50)

Synopsis While several Maintenance personnel were performing an engine wash on a B777, there was a lack of communication between the personnel hand washing the engine fan blades

with a blade lock strap in place and the personnel in the cockpit accomplishing an alternate method by motoring the engine.

ACN: 1379953 (21 of 50)

Synopsis An A320 Mechanic reported being unable to clear an MEL item, and then improperly re-

deferring the valve due to time pressure and inexperience.

ACN: 1379373 (22 of 50)

Synopsis

Mechanic reported on a B737-800, when replacing a tire, he neglected to install the tab

washer.

ACN: 1379368 (23 of 50)

Synopsis Maintenance reported that on a B757 when installing the access panel for the leading edge

slat tracks the mechanic neglected to install five of the six screws required to secure the

panel.

ACN: 1378169 (24 of 50)

Synopsis Maintenance personnel reported when performing a "Zero Rig" procedure on the trailing

edge flaps on a Embraer 145, they neglected to remove a fairing bracket causing damage

to both inboard flaps.

ACN: 1377686 (25 of 50)

Synopsis A Maintenance Inspector reported that someone from his operation had removed parts

from an accident aircraft without proper documentation.

ACN: 1376697 (26 of 50)

Synopsis Maintenance technicians reported deferring the right air-conditioning pack on a B767-300 and that an equipment cooling system failure on the subsequent flight led to the flight

crew donning oxygen masks and using the deferred pack.

ACN: 1376422 (27 of 50)

Synopsis A maintenance technician reported incorrectly installing the fuel pump on a Cirrus SR22 aircraft.

ACN: 1376299 (28 of 50)

Synopsis When maintenance performed a Reverser Operational Check on a B787-8 Aircraft in the

terminal area, the Technician exceeded the reverse thrust idle position causing the engine to exceed the thrust limit for the check.

ACN: 1375119 (29 of 50)

Synopsis

An Aircraft Maintenance Technician working on an MD82 reported finding a 1 and 1/2 inch

crack on the frame of the Left Hand wheel well that went from one rivet to another rivet .

ACN: 1373778 (30 of 50)

Synopsis Maintenance Technician reported that a Service Difficulty Report (SDR) was submitted for

a crack found on an EC135 helicopter nearly a month after discovery due to the

assessment of the condition.

ACN: 1373252 (31 of 50)

Synopsis An air carrier Maintenance Technician reported a health and safety concern over a delay in

addressing mosquitos in the cabin after a flight from Buenos Aires.

ACN: 1371812 (32 of 50)

Synopsis The Maintenance Release Document on a B747 did not reflect which part of the Air Conditioning system was deferred.

ACN: 1371019 (33 of 50)

Synopsis On a B737-800 a #2 Main Landing Gear tire exploded because it was found underinflated

and it was inflated instead of following the maintenance manual which required replacement both #1 and #2 tires.

ACN: 1370905 (34 of 50)

Synopsis A ramp service employee reported that while mechanics were running the engines on an

aircraft, two other mechanics crawled under the aircraft and pulled the chocks.

ACN: 1370601 (35 of 50)

Synopsis Line Aircraft Technician reported finding excessive damage to cargo pit sidewalls in a B737-900 due to wear from rivet heads on the frame. He found holes larger than 1.5

inches which exceeded the limit in the FARs.

ACN: 1370016 (36 of 50)

Synopsis A maintenance Technician installed a "Hot Mic" Switch on the captain's yoke upside-down.

ACN: 1369027 (37 of 50)

Synopsis Maintenance Technician reported their air carrier's B737 fleet are having flight deck doors

modified with new all electric locking systems. Reporter stated the flight deck doors cannot be secured when the locking systems have no power.

ACN: 1368251 (38 of 50)

Synopsis A maintenance Technician reported that after accomplishing an oil service on a Saab

SF340B, the aircraft departed then returned to the airport due to the oil service door coming open in flight.

ACN: 1367076 (39 of 50)

Synopsis During the process of assembling a Pratt & Whitney PW100 gearbox the incorrect tooling was used and the incorrect pressure was applied causing the hydraulic ram to depart and

crashed onto the bullgear and propeller shaft.

ACN: 1366948 (40 of 50)

Synopsis A maintenance technician reported that non maintenance personnel are hand pumping open Airbus cargo doors when the hydraulic system for the cargo doors is deferred per the

MEL.

ACN: 1366311 (41 of 50)

Synopsis When lowering the flaps during maintenance on a B737-700 the mechanic was unaware of a wing stand under the flap fairing. The left wing outboard flap fairing tail cone crushed

into the wing stand.

ACN: 1366195 (42 of 50)

Synopsis A Maintenance Technician reported factory installed PBEs were removed per company instructions, activated, and then disposed. Nine of the eleven PBE packages that failed

during attempted opening were then opened with pocket knives.

ACN: 1366031 (43 of 50)

Synopsis

Air Carrier maintenance Technician reported that while pressurizing an aircraft ground

personnel are attempting to open doors and/or service the aircraft ignoring the warning signs, ie; "beacon light".

ACN: 1363466 (44 of 50)

Synopsis On a Dassault Falcon 7X the basic inspection procedures were not being followed per the

aircraft maintenance manual.

ACN: 1361469 (45 of 50)

Synopsis A Mechanic reported that a Cessna 560XL elevator trim actuator was binding and found to

have internal damage.

ACN: 1360166 (46 of 50)

Synopsis Mechanic reported that while investigating an MEL item, (IDG FEEDER FAULT) on a CRJ-900, found damage to the IDG Feeder wires due to a missing clamp.

ACN: 1359419 (47 of 50)

Synopsis Two maintenance technicians reported that while retracting the Main Landing Gear on a

Bombardier CRJ200 for maintenance, with the MLG door disconnected, the bellcrank was out of the proper position causing the linkage to break and damage to the aircraft.

ACN: 1358749 (48 of 50)

Synopsis Maintenance Technician reported a PT2 (Pressure Total 2) tube "B" Nut was left loose on a

Pratt and Whitney engine for a B777 aircraft.

ACN: 1357713 (49 of 50)

Synopsis Maintenance Technician reported finding a slide pressure hose with frayed braiding, collapsed and contaminated, which was subsequently signed-off by a supervisor and

engineer as serviceable, contrary to the maintenance manual.

ACN: 1355607 (50 of 50)

Synopsis

While working a trim freezing problem on a Cessna CE-560E, Maintenance could not

determine if a Service Bulletin was accomplished on this aircraft to determine which type of grease to use on the trim actuator.

Report Narratives

ACN: 1403720 (1 of 50)

Time / Day

Date : 201611 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

ATC / Advisory.Ground : 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 : Taxi Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Main Gear Wheel Aircraft Reference : X

Problem : Malfunctioning

Person

Reference : 1

Location Of Person : Company Reporter Organization : Air Carrier

Function.Maintenance : Lead Technician

Qualification.Maintenance : Powerplant Qualification.Maintenance : Airframe

ASRS Report Number.Accession Number : 1403720 Human Factors : Training / Qualification

Human Factors : Communication Breakdown Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : Maintenance

Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.Deviation - Procedural : Published Material / Policy

Detector.Person : Flight Crew

When Detected : Taxi Result.General : Flight Cancelled / Delayed

Assessments

Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Procedure Primary Problem : Procedure

Narrative: 1

[The aircraft] departed, then taxied out towards [the runway] when he pulled off the

taxiway and called for maintenance to come look at his #2 wheel due to increasing brake temp, and an earlier report from the pushback crew that the tire was "wobbling". [Three]

mechanics responded and drove out to the south cargo ramp, where it was immediately obvious that something was very wrong with #2 tire, it was cocked at an odd angle and on

closer inspection there was torn metal on the inside of the wheel, with possible damage to the brake assembly. A decision was made to offload the passengers onto busses, transfer

cargo to a new aircraft, and the hangar crew was called to replace the wheel and assess damage to the brake and axle.

My problem with this whole event is that the pilot, told the Hangar Crew Chief that on pushback, the ramp tug driver had called up to him on intercom that they were halting the

pushback prematurely to have the #2 wheel checked out because it was wobbling. Then a few minutes later, he informed the pilot that the tire had been checked out and was ok. No

call was made to maintenance, so I am guessing that the rampers checked the wheel themselves, or maybe called THEIR lead, and they determined the wheel was serviceable.

The tug driver then informed the pilot that the wheel had been checked, and was "ok", which led the pilot to believe that the wheel had been checked by maintenance, which it

was not. This is far beyond the scope of their job, and in this case, could have caused a

serious, if not catastrophic accident. The wheel was obviously damaged, and if the ramp thought the wheel was "wobbling" maintenance technicians should have been called

immediately to check it out.

Passengers had to be offloaded onto busses on the south Cargo Ramp, cargo downloaded and catering accomplished there as well. Hangar crew removed #2 wheel, inspected axle,

and replaced #2 wheel and brake assys.

What I would like to see happen is for the ramp pushback crews to be properly trained on

when to call maintenance, some of them are quick to call us out for non-events like scuffed paint and dents that have damage file stickers right next to them, but again, I feel

this is event was far more serious, and I am thankful the push crews' failure to call maintenance didn't cause any further damage to the aircraft or injury to our passengers.

Synopsis

A Lead Technician reported that when called out to check the Main Landing Gear wheel on an A320, due to high brake temperature, found it unserviceable after the ground crew

released the aircraft calling the wheel okay.

ACN: 1403322 (2 of 50)

Time / Day

Date : 201611

Local Time Of Day : 0001-0600

Place



Aircraft

Reference : X Aircraft Operator : Air Carrier

Make Model Name : B767-300 and 300 ER


Flight Plan : IFR Mission : Cargo / Freight

Flight Phase : Parked Maintenance Status.Maintenance Items Involved : Repair


Component

Aircraft Component : Cargo Door Aircraft Reference : X


Person

Reference : 1


Function.Maintenance : Other / Unknown ASRS Report Number.Accession Number : 1403322

Events


Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Maintenance

When Detected : Routine Inspection Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Manuals

Contributing Factors / Situations : Procedure

Primary Problem : Manuals

Narrative: 1

[This aircraft] has three [orders] for temporary repair of the Main Cargo Door seal

depressors. [Three maintenance procedures] are all sources of temporary or permanent repair depending on which door has the damage, where is the damage located on the seal

depressor, and whether it is a permanent repair or temporary. [An engineering authorization procedure] has just been revised to allow the temporary repair of the seal

depressors if they are out of limits for all other sources the tracking of this EA (Engineering Authorization) is nonstandard tracking form the normal tracking procedures.

The EA tracking criteria was entered in the [system] at the time of issuance as evidenced by the latest MX action, the tracking did not start normally and the reinspect did not get

accomplished.

The OEM (Original Equipment Manufacturer) has very strict tolerances for the seal

depressors on all of the cargo doors on the 767. Due to the extreme number of out of service events in the last 4 months, [company] engineering has been issuing EA's and SR

(Structural Repair) drawing internally to get more relief on the depressor. In all cases the depressor must be inspected in short intervals and replaced with 7 to 10 days depending

on the damage. If the tolerances for Temporary or permanent repair are going to be relaxed in order to meet the flight schedule, then it should be done from a standpoint of

meeting the demand of the problem. As it happens, several EA's have been written and

revised, an SR drawing was released and so on. Each time a different criteria for permanent repair or replacement.

Synopsis

A Maintenance Support person reported that temporary repair procedures for the B767-300F main cargo door seal depressors comes from different sources and are inconsistent,

and the tracking of these repairs is not standard.

ACN: 1400115 (3 of 50)

Time / Day

Date : 201611


Place

Locale Reference.Airport : ZZZZ.Airport

State Reference : FO Altitude.AGL.Single Value : 0

Environment

Light : Daylight

Aircraft

Reference : X Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Phase : Parked Maintenance Status.Maintenance Deferred : Y

Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Galley Furnishing Aircraft Reference : X

Problem : Improperly Operated Problem : Malfunctioning

Problem : Design

Person

Reference : 1 Location Of Person : Company

Function.Maintenance : Technician Qualification.Maintenance : Powerplant

Qualification.Maintenance : Airframe ASRS Report Number.Accession Number : 1400115

Human Factors : Troubleshooting Analyst Callback : Completed

Events


Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : MEL

Anomaly.Deviation - Procedural : Maintenance Detector.Person : Maintenance

When Detected : Aircraft In Service At Gate

Result.General : Maintenance Action Result.Aircraft : Aircraft Damaged

Assessments

Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Procedure Primary Problem : Human Factors

Narrative: 1

Crew landed in ZZZZ. Crew wrote up the following 2 MELs:

1. 25-70 All outlets inoperative - Deferred per MEL; Maintenance procedure accomplished. 2. 25-70 GFI (Ground Fault Interrupter) cover damaged - by sink in galley Deferred per

MEL; Maintenance procedure accomplished.

Aircraft flew from ZZZZ to ZZZ the next day and maintenance was set up to address the above MELs. While technicians were troubleshooting the system they found the following:

"The galley outlet in question is working now so I'm guessing the enormous toaster shown is being used directly underneath the outlet area and tripped the GFI and also melted the

laminate. Definitely need to examine the GFI underneath though as you can see the black

melted plastic coming from the holes. The crew is lucky they didn't set the galley on fire. I'm thinking [Company] Safety should be involved with this to issue a warning to flight

crews. They shouldn't be using such big toasters in such a confined area. It's a potential disaster waiting to happen."

In summary, the toaster was operated in very confined area with a low ceiling. The heat

coming from the toaster melted the panel directly above it. This panel has the GFI installed in it which was also melted. Inspections of GFI and outlet wiring showed no

defects leading us to believe the issue was not with the electrical system but rather the

heat radiating from the toaster when it is in use. The plug of the toaster also showed no signs of damage. I am requesting an immediate investigation on how the toaster and

other galley utensils that ops places on the aircraft after conformity are selected and can be guaranteed to be safe to operate on the aircraft. Also we need to express concern to

the flight crew that using something that creates heat in a confined area is not safe and [can] lead to an inflight fire.

Callback: 1

The reporter stated that the toaster used is for customer and/or crew convenience. The

toaster is normally stowed in an area where baggage and other items are stored. It is not permanently mounted anywhere. The crew used the toaster in an area that was not

properly ventilated which caused the overheating of the GFI and the plastic laminate. The toaster that was used is not standard equipment for this aircraft. There was no damage to

the aircraft wiring. The only damage was to the area around the toaster. The reporter stated that this is still an ongoing investigation.

Synopsis

Maintenance Supervisor reported technicians found a large non standard toaster was used directly beneath an outlet area while working on an aircraft. The heat generated tripped

the Ground Fault Interrupter (GFI) and melted the plastic panel above the toaster.

ACN: 1398810 (4 of 50)

Time / Day

Date : 201610


Place

Altitude.AGL.Single Value : 0

Aircraft

Reference : X Make Model Name : Embraer Undifferentiated or Other Model

Flight Phase : Parked

Component

Aircraft Component : DC Ram Air Turbine Aircraft Reference : X

Problem : Improperly Operated

Person

Reference : 1

Location Of Person : Company Function.Maintenance : Inspector

ASRS Report Number.Accession Number : 1398810

Events

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

Detector.Person : Maintenance When Detected : Routine Inspection

Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Chart Or Publication

Contributing Factors / Situations : Manuals Contributing Factors / Situations : Procedure

Primary Problem : Procedure

Narrative: 1

There has been mention by management that it has been observed that the Ram Air Turbines have been found to have been stowed incorrectly. This incorrect stowage is

causing the Ram Air Turbine to not drop out of the fuselage cutout properly when deployed. This scenario has recently been discovered at the maintenance hangar where a

RAT was deployed and stuck, unable to fall out of and free from the fuselage cutout. This incident like others before it causes damage to the Ram Air Turbine blades. With this being

a known issue and affecting multiple aircraft recently I find it hard to fathom that a fleet

campaign has not been implemented to inspect for the proper positioning of the RAT blades in the stowed position. This would help confirm that if a RAT is indeed needed for

an in-flight electrical emergency that it will deploy as designed and possibly save lives. It would appear that the only concern to date is how do we prevent future damage and cost

savings. While these are both valid concerns I believe it is of greater importance to make

sure that the current RAT's in service are properly stowed. It should also be noted that the stowing of the RAT is deemed to require a second set of eyes according to the job cards,

but if a RAT is deployed and stowed at any other time it is not required to have a second set of eyes. Due to recent events I feel that the stowing of the RAT should be considered

as a candidate for the Required Inspection Item List. There has been a Service Bulletin from [the manufacturer] alerting operators to the importance of the RAT retraction

procedure.

Synopsis

A Maintenance Inspector reported that some Ram Air Turbines (RAT) are not properly stowed, when this occurs the RAT is unable to deploy.

ACN: 1398441 (5 of 50)

Time / Day

Date : 201610


Place



Aircraft

Reference : X Aircraft Operator : Air Taxi

Make Model Name : EC135

Operating Under FAR Part : Part 135 Mission : Ambulance

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 : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Installation

Component

Aircraft Component : Main Rotor Blade Aircraft Reference : X


Person

Reference : 1

Location Of Person : Company Reporter Organization : Air Taxi

Function.Maintenance : Technician

Qualification.Maintenance : Airframe Qualification.Maintenance : Powerplant

ASRS Report Number.Accession Number : 1398441 Human Factors : Troubleshooting

Events


Detector.Person : Maintenance

When Detected : Routine Inspection Result.General : Maintenance Action

Assessments

Contributing Factors / Situations : Aircraft


Narrative: 1

During Track and balance of Aircraft X, it was determined a Main Rotor (M/R) blade was needed. Mechanic I was working with and I removed blade and replaced with the same

part number we removed. We finished track and balance and accumulated 0.3 flight time while completing the job. Upon return to the hangar to remove tracking equipment Quality

Assurance (Mechanic) informed us that we installed the wrong Part Number.

We reviewed the paperwork from both blades and determined it was not an upgraded

blade that was installed. To upgrade the blade a Service Bulletin needed complied with installing upgraded dampeners. We installed the upgraded dampeners on the blade in

question and corrected paperwork to reflect the change to the blade. The aircraft was then placed back in service.

It was found that the removed blade was not properly identified, as per the Service

Bulletin, to reflect it was an upgraded blade. The Service Bulletin states that a line will be

drawn through the last two digits of the part number. In this case it would have been the number XY. Further, the number XZ will be written in permanent marker next to the lined

out number. The removed blade did not have a line through the last two digits and the XZ was not legible.

Synopsis

A Maintenance Technician reported that During Track and balance on a EC-135 Helicopter, a Main Rotor blade was needed. Upgraded the existing blade per a Service Bulletin.

ACN: 1397957 (6 of 50)

Time / Day

Date : 201610


Place



Aircraft


Make Model Name : A319



Flight Phase : Parked Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Pax Seat

Aircraft Reference : X Problem : Design

Person


Location In Aircraft : General Seating Area Reporter Organization : Air Carrier

Function.Maintenance : Technician Qualification.Maintenance : Airframe

Qualification.Maintenance : Powerplant


Events


Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : FAR

Detector.Person : Flight Crew Result.General : Maintenance Action

Assessments

Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part

Primary Problem : Incorrect / Not Installed / Unavailable Part

Narrative: 1

Today at XA:15 local time, I was assigned a right start on an aircraft. At approximately

XA:45 the flight crew notified me that the seat backs on row 13 had tray tables that fold down and open into emergency row 14. After inquiring with tech services we agreed it did

not seem safe for those tables to be installed and operable.

My immediate supervisors then contacted and investigated with engineering. Engineering confirmed that it was okay for those tables to be present and operable.

I have a safety concern that during an emergency these tables could open inadvertently

and block emergency egress. I found the same configuration on other aircraft in this fleet.

Is this installation safe and legal?

Flight attendant reported to flight crew when she noticed tray tables mounted on backs of row 13. These tables could be opened and block emergency exit row 14 and impede

egress.

I suggest these tables be permanently secured/deactivated in the stowed position, or removed entirely to avoid inadvertent opening during an emergency. This action would

also avoid delays while determining if this installation is correct.

Synopsis

A Technician on an Airbus A319 reported that tray tables are mounted on the backs of seats in an emergency exit row.

ACN: 1397700 (7 of 50)

Time / Day

Date : 201610


Place


State Reference : US Altitude.MSL.Single Value : 0

Aircraft


Make Model Name : B737 Undifferentiated or Other Model



Flight Phase : Parked Maintenance Status.Maintenance Type : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Work Cards

Component

Aircraft Component : Trailing Edge Flap Manufacturer : Boeing

Aircraft Reference : X Problem : Improperly Operated

Person : 1

Reference : 1 Location Of Person : Repair Facility

Reporter Organization : Contracted Service Function.Maintenance : Other / Unknown



Human Factors : Situational Awareness Human Factors : Communication Breakdown

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

Person : 2

Reference : 2

Location Of Person : Repair Facility Reporter Organization : Contracted Service


Human Factors : Situational Awareness Human Factors : Communication Breakdown



Events


Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Object


Result.General : Maintenance Action

Result.Aircraft : Aircraft Damaged

Assessments

Contributing Factors / Situations : Human Factors

Primary Problem : Human Factors

Narrative: 1

To perform the lube of the aft trunnion pins, I cleared person X to lower the flaps. Person

X was in the cockpit and I was on the ramp. Remembering the flaps were cleared and fully extended a short time prior during the flap inspection for the MV2, I failed to look and

double check that the area was safe for the flaps to be extended. As person X lowered the

flaps, I walked to the right wing to continue with the lube card. 2 minutes later person X approaches me and informs me the flaps were lowered onto the golf cart which was

located beneath the left wing. The flap had a 2x1 inch delamination on the inboard trailing edge corner. A temporary repair was performed and logged in a non-routine with a

permanent repair required within 150 flight hours.

Narrative: 2

After normal MV2 flap inspection, with flaps retracted, I parked a golf cart under the left

wing trailing edge to use the LED headlights for completion of #1 engine T/R slider Airworthiness Directive (AD) inspection. After the inspection was completed, I neglected to

immediately move the cart out of the way. When the flaps were lowered again for the

main gear lube the trailing edge outboard Flap, inboard corner contacted the roof of the golf cart and was damaged.

Synopsis

Maintenance Personnel reported that when lowering the flaps on a B737 the flaps contacted the roof of a golf cart.

ACN: 1397179 (8 of 50)

Time / Day

Date : 201610


Place



Aircraft



Operating Under FAR Part : Part 121 Flight Phase : Parked


Component

Aircraft Component : Pax Seat


Person

Reference : 1

Location Of Person : Company Location In Aircraft : General Seating Area

Reporter Organization : Air Carrier Function.Maintenance : Other / Unknown

Qualification.Maintenance : Repairman ASRS Report Number.Accession Number : 1397179

Events




Assessments

Contributing Factors / Situations : Company Policy Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Manuals Contributing Factors / Situations : Human Factors


Primary Problem : Company Policy

Narrative: 1

Aircraft [is an] example of a fleet problem in new Boeing 737 Aircraft; A Boeing aircraft

has an Airbus seat interior, this sets up huge problems in looking up parts in the IPC for a 737 seat but we are now dealing with a mix of Airbus and Boeing together.

Example in changing what is supposed to be a simple hydrolock on a seat recline not

working. It took 2 hours for us to figure out a superseded part on an Airbus interior. This sets up the mechanic for a double edge sword. Why do we not have regular seats on

Boeing??? This causes confusion.

Additionally the Airbus seats must be the cheapest to buy in the industry, breaking easy

with seat pans and hydrolocks and hard to repair.

Synopsis

A maintenance person reported that Airbus seats are being used in Boeing aircraft which

makes it difficult locating parts.

ACN: 1394256 (9 of 50)

Time / Day

Date : 201610


Place



Aircraft

Reference : X Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil


Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Helicopter Gearbox and Drive Aircraft Reference : X

Person : 1





Person : 2





Events


Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR



Assessments



Narrative: 1

I was instructed to perform a rigging check of the Main Rotor Controls. The Servo Input rods were previously disconnected from the Main Rotor Servo Input levers because of

other maintenance performed. I performed the rigging as instructed and found everything within limits. No adjustments were necessary. Upon completion of the rigging, I proceeded

in installing the Input Rods on to the Main Rotor Servos. At that time, I received the bag of

hardware that contained the original hardware stack up, including 2 "diaper" safety pins. I question the safety pins at that time, being there was only 2 pins and 3 bolts. [Another

technician] informed me that the Right and Left Aft servos were pinned originally, and the forward was cotter pinned. I did not think, at the time, there was anything wrong with

using safety pins in place of cotter pins on the Main Rotor Servos. I have seen this many times before on various helicopters, including AS350's. I then inspected the hardware and

pins, and found nothing wrong with them, so I proceeded to install the bolts in accordance with the appropriate maintenance manual reference and contacted the aircraft Quality

Assurance inspector for an "OK to close" for the plastic ice shields installed over the Input

Rod Levers. At that time [the Quality Assurance inspector] questioned why there were only two safety pins, and one cotter pin. I replied that is how it was originally, and that I had

seen safety pins in that position previously. He agreed, so I continued, and installed the Ice Covers.

I believe complacency, a lack of attention to detail, and a lack of training were the main

causes of this event. I never questioned the use of safety pins there because I had seen them multiple times in that location. Upon research I found a standard practices reference

in the AS350 SPM that noted the use of safety pins in the Main Gearbox Suspension bars,

and in cowling latches. As well as their use in "plain pins". However, I could not find any reference to using them in place of cotter pins on bolts. I think this is a common mistake,

and the cause of them being installed in this location on other aircraft. Making me complacent, because of my previous experience, and the mentality of "that's how it came

in".

Narrative: 2

After [a technician] installed the oil line from the oil cooler to the main gearbox, I

inspected it and stamped the inspector block. The fitting in the gearbox was safety wired but the line was not. Looking at it, it appeared to be safetied to me.

When inspecting the main servo flight control input rods that [another mechanic] installed, one of the nuts was safetied with a cotter pin and the other two were safetied with diaper

pins. I asked if it was acceptable to safety them like that and was told yes there is a statement in the book that says its okay. I did not verify the book and accepted the

answer. We were incorrect and the book shows cotter pin in the nuts.

Both of these items were discovered by the technician receiving the aircraft in the field

Pay closer attention to the safeties on the aircraft when in doubt double check the manual

for correct hardware.

Synopsis

Mechanic reported failing to verify that the cotter pin in the nuts when inspecting the main

servo flight control input rods on a Eurocopter AS350. One of the nuts was safetied with a cotter pin and the other was safetied with diaper pins.

ACN: 1394255 (10 of 50)

Time / Day

Date : 201610


Place



Environment

Light : Daylight

Aircraft

Reference : X Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil


Maintenance Status.Maintenance Items Involved : Work Cards Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Helicopter Gearbox and Drive Aircraft Reference : X


Person

Reference : 1 Location Of Person : Hangar / Base

Reporter Organization : Contracted Service Function.Maintenance : Technician



Human Factors : Situational Awareness

Events




Assessments



Narrative: 1

Aircraft was in for multiple inspections with multiple components removed from the aircraft

including the main transmission and hoses. Upon installation, to the best of my ability, of the main transmission in accordance with the Aircraft Maintenance Manual, I forgot to

safety the input oil line to fitting on the main transmission.

To avoid recurrence of this event I will pay closer attention to detail of work performed in accordance with the maintenance manual.

Synopsis

Mechanic reported he forgot to safety the input oil line to fitting on the main transmission

on a Eurocopter AS350.

ACN: 1394006 (11 of 50)

Time / Day

Date : 201610


Place



Aircraft


Make Model Name : B777-200

Operating Under FAR Part : Part 121 Mission : Passenger

Flight Phase : Parked Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Interior Door

Aircraft Reference : X


Person

Reference : 1




Human Factors : Workload

Human Factors : Communication Breakdown Communication Breakdown.Party1 : Maintenance


Events





Assessments





Narrative: 1

I was assigned to work [this] aircraft. I was also assigned other turnaround trips which

required me attending to first due to their scheduled departure times. [This aircraft] had arrived with three pages of inbound items and several items assigned on the Bill of Work

(BOW). I proceeded to assess the inbound items one in particular the Flight Crew Rest area (FCR) door. My partner had gone to the aircraft and called me to inform me the FCR

door was in fact jammed shut. I pulled a history and found this was a fourth time repeat

item, with a fifth item for a missing trim on that very door. I then proceeded to call Tech to discuss the issue at hand. There is an MEL relief for this item (MEL 25). Tech expressed

his concerns and I agreed with him, option A, leaving the door intact would not alleviate the possibility of a crew member becoming trapped in flight. We both looked into option B

which removes the door and stows it rendering the FCR unusable through [an] MEL, and limits crew duty times REF MEL 25. Tech and I were conferring with dispatch to see if this

was a viable option. It was at this time I was approached by supervisor and told to "Get with Tech crew chief and go out to the plane." I explained to him I was in the process of

resolving it with Tech and dispatch on the phone. He became irate and told me to go to

the plane now or he would have me removed from the aircraft. I once again explained I was on the phone with Tech and dispatch. He then accused me [of] sabotage by only

trying to ground the aircraft. He then approached crew chief and once again accused me of sabotage and demanded I be removed from the assignment. The accusation of sabotage is

one I take very seriously and could not be further from the truth, safety of the crew and passengers is my primary concern. I was simply trying to accomplish the task at hand in

accordance with [the airline] published MEL paperwork.

Synopsis

A Mechanic reported while in the process of getting authorization to defer a Crew Rest

Area door on a B777, a Supervisor became irate and removed him from the assignment.

ACN: 1391027 (12 of 50)

Time / Day

Date : 201609


Place


Aircraft


Make Model Name : Jet Ranger All Series Undifferentiated or Other Model Operating Under FAR Part : Part 135



Component

Aircraft Component : Tail Rotor Drive Gearbox Aircraft Reference : X

Problem : Design

Person : 1

Reference : 1

Location Of Person : Company

Reporter Organization : Air Taxi Function.Maintenance : Technician


ASRS Report Number.Accession Number : 1391027 Analyst Callback : Completed

Person : 2

Reference : 2

Location Of Person : Company Reporter Organization : Air Taxi



Person : 3


Reporter Organization : Air Taxi

Function.Maintenance : Technician Qualification.Maintenance : Inspection Authority


Events



Detector.Person : Flight Crew When Detected : Routine Inspection


Assessments


Contributing Factors / Situations : Company Policy


Narrative: 1

We received this aircraft from another base, it was used for pilot training [that] night. I did an airworthiness check on it today and noted many differences/mods from our normal

base aircraft. I also noted that there was a hole cut in the Tail Rotor Gear Box (TRGB) cover to check the oil level of the TRGB. This is something I have seen in other aircraft so

I did not take particular notice of this. Additionally I noted that the hole was obviously there when the aircraft was painted due to the condition of the paint around the hole

indicating it had been there since before the aircraft was painted. The Check Airman came

in later this evening and noted the hole in the cover and asked if I had seen anything in the aircraft documents that would allow for the hole in the TRGB cover. I was not able to

find anything on short notice. The Check airman made an entry in the aircraft log book as a "suspected unapproved Modification". I removed the aircraft from service and ordered a

replacement cover.

During the conversation the Check Airmen stated that there were several aircraft that had the hole done and did not have any approval. [Company] has done these in the past and if

[they are] aware of these as "unapproved Mods" it should be forwarded to all [Company]

bases that these are not authorized and if there is a hole in the TRGB cover it must be replaced.

It would be helpful if there was a way to document minor modifications, IE like 337's. So

you could search for minor modifications to airframes. Over the years there have been many minor mods that only have log entry's or are buried in some work order that we do

not have access to, these are done during maintenance, work orders and outside vendors. If we do not have ready access to a list of these we are unable to quickly or easily

reference any minor modification, repair or inspection. Inspected a dent in the finlet on a

407, you can circle the dent with a marker and date & initial it. But in 6 months any marking of that on the ship will be gone. Then a FAA guy comes in and asks if this was

check. All I can say is yes it was check a while back but there would only be a nondescript entry to find in a stack of old log books.

Callback: 1

The reporter stated that the hole for the gear box cover is actually a hole in the aft tail rotor fairing, which covers the TRGB. There are cooling holes on the fairing and the hole is

question is an enlargement of several holes together to allow access to the TRGB sight

gage. The reporter stated, subsequent to the writing these reports Bell Helicopter has issued a letter of "No Technical Objection" to the making of the hole in question. The letter

was inserted into the logbook. The reporter stated the issue with the flight crew is that

they couldn't find any record of the modification to the fairing due to the age of the

helicopter and how long ago it was done.

Narrative: 2

I was tasked to support Aircraft X while it was in for pilot training. Once it arrived I began

to configure aircraft for dual pilot operations by installing dual controls. I then conducted an AWC and I did notice differences in this BH 407 such as loading lights on top of

fuselage, different medical interior setup, different searchlight option, different engine oil that it was currently using and that it did have a hole in the tail rotor gearbox cowling to

allow for increased visual observation of tail rotor sight glass. I determined that it was in

an airworthy status for that evening's scheduled pilot training flight. I spoke with Lead Mechanic about these differences; he did complete the Required Item Inspection (RII) on

the maintenance performed on this aircraft and we spoke about the differences in this aircraft compared to our programs BH 407's, nothing stood out as not being safe for flight.

The instructor pilot then flew aircraft later that evening and I did not hear from him if he had any discrepancies to report after the training flight [that] night. It wasn't until the

next evening that a different instructor pilot spoke to the Lead Mechanic about what he found. He then informed me about what happened. [A] Pilot reported the discrepancy with

the hole in the Tail rotor gearbox cowling suspecting an unapproved modification.

This aircraft was moved out here to support pilot training; if this aircraft had a list of all

STC's or all modifications / 337's on board the aircraft or in an accessible spot so that the instructor pilot, trainee pilot or mechanic could use to answer questions that are brought

up while conducting a preflight, then the pilot should be able to find the information required to answer any questions about the aircraft, anywhere at any time. The fact is that

this modification has been on the aircraft for a while, before it transferred [here], and without being able to have the documentation available to prove that it was done properly

to anyone who suspects an unapproved modification, then we have no choice but to

remove suspected bad part and install new one on this aircraft.

To avoid any recurrence of this happening again, with any aircraft that moves out of its home region to support operations elsewhere, maybe it should have a list of modifications

incorporated in the [paperwork] that a pilot (or mechanic) can look and see if any modification has been approved, when it was approved and by who it was approved, to

include the logbook number, log page number and log card number. This will enable any pilot/mechanic the ability to quickly look up the info and show that just because a part is

modified, such as the tail gear box cowling inspection hole, that it was done properly. This

will avoid any situations that will require new parts to replace the "suspected bad" part. Without this quick access sheet, then it will be a document hunt that will take a while to

find the logbook entry or work order that this was completed under. Other aircraft in the [Company] fleet have documentation that allows this to be done in the field.

Narrative: 3

We were using this aircraft as a spare while our primary ship was down for maintenance. I noticed that the Tail Rotor Gearbox fairing screen had an enlarged hole for viewing the

TRGB fluid level. I was not overly concerned as I have seen other aircraft with the hole enlarged and this one had clearly been there a long time as the aircraft had been

repainted and it was apparent the hole was there prior to paint. I did contact the mechanic

where the aircraft came from to ask him if he had any knowledge or documentation. He said he did not, and that the aircraft came to his base with that hole a couple years earlier.

So, I sent a picture of the screen to my supervisor. He said he had also seen this on other aircraft and instructed me to send the picture to the tech rep after checking the

Maintenance Manual (MM). The only information I could find was to inspect the screens

and make sure they "were not clogged and that they were in good condition." (MM Ch. 53-86, 2) I sent the picture to the tech rep and received an email saying that they were

looking into the issue. There was no apparent urgency on anyone's part. So based on the universal reaction and since I am fairly new to 407s my assumption was that this must be

fairly common and no big deal. I believe that the person that made the original modification also made a log entry. It would have been years ago and now difficult to find.

The issue came up before I received a reply. The aircraft had been relocated back. A check

airman wrote the issue up as a suspected undocumented modification after he had found

similar mods [on other aircraft]. A replacement TR fairing was ordered.

If it turns out that this is just a simple minor alteration, it would be helpful if there were some listing for each aircraft of minor alterations. Or perhaps a universal document listing

common minor alterations on various airframes could be compiled over time. Or if these things are being discovered by check airman, there could be a way they could

communicate finding to maintenance so that 1 new finding is known fleet wide in short order.

Synopsis

Several mechanics reported that a BHT-407 Helicopter aft tail rotor gear box fairing had an

undocumented hole added to access the gear box oil level site gage.

ACN: 1388975 (13 of 50)

Time / Day

Date : 201608


Place



Environment

Light : Night

Aircraft


Make Model Name : B737-800 Operating Under FAR Part : Part 121


Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Work Cards


Component

Aircraft Component : Elevator Tab Manufacturer : Boeing


Person

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 : 1388975

Human Factors : Troubleshooting

Events



When Detected : Routine Inspection


Assessments


Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft

Primary Problem : Incorrect / Not Installed / Unavailable Part

Narrative: 1

I performed [a taskcard] in a Quality Control inspector capacity and missed an extra

washer installed on the left-hand horizontal inboard elevator tab control rod on the inboard bushing side causing to only have two threads showing on the bolt behind the nut instead

of three threads. All other hardware are the correct ones and effective for the said aircraft.

There was no binding or damage found. The elevator tab had free range of motion. [Discovered by] scheduled routine inspection and also due to hardware issues from newly

painted airplanes from vendor that had wrong or missing hardware installed.

While accomplishing the taskcard and doing the inspection, the extra washer was missed because the area of inspection was covered by grease and it looked like it was part of the

bushing. I figured that all hardware installed was secured and tight and that two threads showing was sufficient enough as per industry standards. The mechanic removed the extra

washer and reinstalled everything back together thus getting the three threads showing

required that was issued for the discrepancies found on other newly painted airplanes from the vendor.

Synopsis

Aircraft Inspector reported while accomplishing a routine inspection he missed an extra washer that was installed on an elevator tab control rod.

ACN: 1386725 (14 of 50)

Time / Day

Date : 201609

Place


Aircraft

Reference : X

Aircraft Operator : Air Carrier Make Model Name : B787 Dreamliner Undifferentiated or Other Model


Component

Aircraft Component : Fan Reverser

Manufacturer : Boeing Aircraft Reference : X


Person

Reference : 1



ASRS Report Number.Accession Number : 1386725 Human Factors : Situational Awareness

Events





Assessments

Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part


Narrative: 1

I was called by a colleague who had a Engine 1 Reverser log item. He was accomplishing a

FIM test and I had to open the fan cowls and exercise the maintenance switch on the

outside fan area. The message remained latched so after ensuring the area was clear of equipment and personnel he exercised the reverse from stow to reverse while I activated

the maintenance switch. When the reverser stowed I spotted splinters of wood falling from the cascade vane area from the inboard side.

When we then deployed the reverser I found that there was a length of 4x2 inch wood approximately 2 feet long broken into pieces sitting on top of the 5:30 position cascade

vane. It had caused damage to the cascade vane and an l duct section.

The aircraft remained overnight and departed with the reverser on MEL and a missing cascade on cdl.

As the wood did not enter through the fan then I believe that it was either placed behind

the fan blades or in the reverser cascade area as part of a mm process at a previous

station. Maybe used as an unapproved tool and undocumented.

The least likely idea is that it was a malicious act and placed there on purpose.

Synopsis

A Maintenance Technician reported finding a piece of 2x4 in a B787 reverser that caused

damage to a cascade vane and an L Duct section.

ACN: 1386256 (15 of 50)

Time / Day

Date : 201609


Place



Aircraft : 1



Operating Under FAR Part : Part 121 Flight Phase : Taxi

Aircraft : 2

Reference : Y Aircraft Operator : Air Carrier

Make Model Name : B777 Undifferentiated or Other Model Operating Under FAR Part : Part 121

Flight Plan : IFR

Flight Phase : Taxi

Person : 1

Reference : 1


Function.Ground Personnel : Other / Unknown Function.Maintenance : Technician



Human Factors : Situational Awareness Human Factors : Training / Qualification


Communication Breakdown.Party2 : Ground Personnel

Person : 2

Reference : 2


Reporter Organization : Air Carrier Function.Ground Personnel : Other / Unknown




Human Factors : Training / Qualification



Person : 3

Reference : 3


Function.Ground Personnel : Other / Unknown



Human Factors : Communication Breakdown Human Factors : Time Pressure

Human Factors : Workload Human Factors : Situational Awareness



Person : 4

Reference : 4





Human Factors : Communication Breakdown Human Factors : Time Pressure

Human Factors : Training / Qualification Human Factors : Situational Awareness

Communication Breakdown.Party1 : Maintenance Communication Breakdown.Party2 : Ground Personnel

Person : 5

Reference : 5




ASRS Report Number.Accession Number : 1386262 Human Factors : Communication Breakdown

Human Factors : Time Pressure



Person : 6

Reference : 6

Location In Aircraft : Flight Deck Reporter Organization : Air Carrier






Events


Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Aircraft

Detector.Person : Maintenance Were Passengers Involved In Event : N

When Detected.Other


Assessments

Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Procedure


Narrative: 1

Tug driver in TLD tug, during pushback struck an aircraft parked behind the aircraft I was

pushing back. I volunteered to help push Aircraft X off of Spot X and tow it to Spot Y as no

one on Taxi Two Crew 2 was qualified on the TLD. Crew 2 and a Tail Walker were involved in the push.

The move was not assigned to the correct Crew, as no one on Crew 2 was qualified to

drive the TLD.

After completing our last minute move I rushed to help Crew 2 complete the move of Aircraft X. I was not part of Crew 2 and arrived at the airplane prior to the rest of the

crew.

The TTWS is only tested prior to our first move of the day and then left armed until we

clock out and leave for the day. The TLD is shared equipment, and the system was turned off prior to this move.

The TTWS should be on and armed once the tug is started. It should not have the ability

to be switched off. 777's should no longer be parked at Spot X. The overall lack of training needs to be address in a timelier manner.

Narrative: 2

I was assigned to move Aircraft X on hangar Spot X. My assignment was ground crew. I

was walking the left wing. I had my TTWS wands. Followed my wingtip. Was not in view of accident. Was on opposite side of aircraft.

I feel the tow team warning system failed.

Better warning system. Discontinue parking B777 on Spot X.

Narrative: 3

On Aircraft X I was the tail walker. We were in process of relocating aircraft and the right

wingtip struck the right elevator of Aircraft Y. I did not see that the aircraft was going to hit the other aircraft. I was using the regular wand at the time.

Taxi tow warning system failed.

I felt rushed and in a time constraint situation. As do all the other team members in the

move. I don't think we should be pressured and rushed to accomplish my work in a safe manner. Because they called me to accomplish a move that takes about 1/2 hour I don't

think there was enough time afforded me for a safe move.

Narrative: 4

I was the right wing walker on Aircraft X pushing out from Spot X. I arrive under the tail of Aircraft Y. At approximately 10 to 15 feet I start pressing the TTWS wand to alert the TLD

driver to stop.

I was wing walking and facing the driver of the TLD vehicle but because of the glare on the windshield I could not see the driver's face. I assumed the push was going on as normal.

The driver is very skilled and familiar with this area. When I realized he may possibly not see what was going on I pressed the button for the TTWS to warn him that he was getting

close. I kept pressing the button as he was not stopping I was not sure if there was failure

of his brakes or my wand. It came to the point where I panicked and started waving. The panicked made me lose my training momentarily everything went too fast at that point.

The whole day followed normal practice and everything seemed great.

The TTWS system should be tied into the power of the TLD so that when the tug is on the system is on. Also maybe a notification on the wand that it is communicating with the tug.

There should not be a 777 parked on Spot X while a 777 is parked on Spot A especially

while the hardstands are occupied by other aircraft. There just isn't enough room to move

safely.

Narrative: 5

Assigned to move Aircraft X to Spot B. I was the Radio Man on the TLD Called for push

Back and Aircraft collided with Aircraft on Spot A. We had a full taxi tow team with a brake rider.

777 park on Spot X with other Aircrafts on Spot B and Spot C provides very little room for

maneuvers. We told management several time before this is not a safe condition.

We should not be putting 777's on Spot X and Spot A. The TTWS system should be

powered on when the tug is on and running at all times.

Narrative: 6

I was a brake rider on Aircraft X at the moment of accident not knowing what happen. I

was not in the position to say the determining factors.

Synopsis

Several mechanics reported that when pushing back a Boeing 777 the TTWS (Tow Team

Warning System) did not function and the aircraft's RH wing tip struck the RH elevator of another aircraft.

ACN: 1383504 (16 of 50)

Time / Day

Date : 201608


Place


State Reference : OH Altitude.AGL.Single Value : 0

Aircraft

Reference : X Make Model Name : BAe 125 Series 800

Crew Size.Number Of Crew : 2

Mission : Passenger Flight Phase : Parked

Component

Aircraft Component : Fuel Line, Fittings, & Connectors Manufacturer : British Aerospace

Aircraft Reference : X Problem : Failed

Person

Reference : 1

Location Of Person : Company Function.Maintenance : Technician



Events

Anomaly.Aircraft Equipment Problem : Critical


Detector.Person : Flight Crew When Detected : Aircraft In Service At Gate

Result.General : Flight Cancelled / Delayed Result.General : Maintenance Action

Assessments

Contributing Factors / Situations : Aircraft Primary Problem : Aircraft

Narrative: 1

The flight crew wrote up, repeat write up. Discovered a fuel leak and appears to be coming

from rear bay. Aircraft was fueled about 45 minutes before leak was noted. No leak was seen prior to fueling. When I arrived at the aircraft fuel was on the ground aft of the right

main landing gear. The tailcone had a strong fuel odor.

I was unable to produce any leakage refueling. I ran the APU and at shut down a large

amount of fuel drained into the tailcone from within the APU enclosure. I discovered the fuel line elbow leaking at the output of the APU Fuel Control Unit (FCU). The fuel was

spraying on to the starter generator, exciter and hot case of the APU. The APU containment box did not contain the fuel and it ran down all the hot bleed ducting and

electrical panels below the APU.

I discovered the elbow had been installed improperly with the o-ring on the threads and not on the recess of the elbow. The leak was very pronounced after the APU was shut

down, the shut off valve downstream closes and the fuel pump continues to turn as the

APU spools down. Spraying atomized fuel on the entire APU.

The containment box has no gaskets by design and the fuel leaks all over the tailcone before it reaches the enclosure overboard drain. I can't explain why this aircraft did not

catch fire.

The enclosure did not trap the fuel and allowed it to leak into the tailcone. There are no gaskets or sealant on the panels to prevent the fuel from leaking out.

Synopsis

A Mechanic reported that a British Aerospace HS-125-800 had a fuel leak from the APU

Fuel Control and it was not contained in the in the APU Containment Box.

ACN: 1382155 (17 of 50)

Time / Day

Date : 201608


Place


State Reference : CA Altitude.AGL.Single Value : 0

Aircraft


Make Model Name : B737 Next Generation Undifferentiated



Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Unscheduled Maintenance

Component

Aircraft Component : Intake Ice System



Person

Reference : 1


Function.Maintenance : Lead Technician ASRS Report Number.Accession Number : 1382155



Events


Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew


Assessments


Contributing Factors / Situations : Manuals

Contributing Factors / Situations : MEL Contributing Factors / Situations : Procedure


Narrative: 1

[This aircraft] had just pulled into [the] Gate. As parts of the meet and greet requiring

Line Technician, I came to the flight deck to meet and greet the inbound flight crew a few minutes after that. As I made my presence known to the inbound flight crew, the captain

immediately told me about his observation during aircraft taxi into the gate that the #2 engine Anti-Ice Light on bright blue while switch in off position.

Realizing that there is a clear discrepancy between the # 2 Engine Anti-Ice Valve and the

associated switch in the off position, I then told the captain that I will need to do some research on this. Back to our maintenance office with the aircraft log book, I began my

research by looking up aircraft maintenance history and discovered that on the previous

day, the #2 engine anti-ice valve has been replaced with a new engine anti-ice valve at another line maintenance station. Due to a repeated write up in two days, my next step

was to pull up the MEL manual and to determine which MEL that would apply to the #2 engine anti-ice valve. As got the MEL manual open up, I called Maintenance Controller to

notify him about the inbound pilot report and my research regarding the reported defect and wanted to apply an MEL 30-3C to the effected valve.

The MEL 30-3C refers to Aircraft Maintenance Manual (AMM) for maintenance procedures

on how to prepare the aircraft for flight with the engine anti-ice valve inoperative. As per

AMM Task 30-00-00-040-803 the engine anti-ice valve can be deactivated by locking them closed or open. I chose option 1 that is to manually position the #2 engine anti-ice valve

Inoperative Closed, because it is shorter procedures to perform comparing to the Option 2 Engine Anti-Ice Valve Inoperative Open.

Having [Maintenance Controller's] concurrence with the applicable MEL 30-3C, I went back

to the aircraft along with another mechanic, who would help me with opening the #2 engine R/H cowl for access to the anti-ice valve. With the #2 engine R/H cowl open and

using a 6 feet ladder positioned adjacent to the #2 engine, I was in a position to manually

put the #2 engine valve in a closed position. Before attempting to turn the valve to a close position, I needed to find out how to determine which direction to manually turn the

affected valve to a close position. From a top view looking at the override knob, I could only see an arrow pointing aft of the #2 engine on the manual lock assembly. Further

examination, I noted that on the valve body assembly, there is also an arrow pointing forward, which indicates the direction of the air flow. Based on my experience of working

with similar pneumatic valves on a different systems, when a valve is in an open position, the arrow on the manual knob indicator would normally pointing parallel to the valve body

assembly, and when a valve is in a closed position, the arrow on the manual knob

indicator would be perpendicular to the valve body assembly.

Based on these two arrows' orientations being parallel to one another and the Bright Blue Light observed in the flight deck, indicating that #2 engine anti-ice valve partially open. It

is reasonably to say that I should turn the manual clock so that the arrow on the manual clock assembly would be perpendicular to the arrow on the valve body to set the #2

engine anti-ice valve closed.

The AMM Task does not include a view of the engine anti-ice valve manual override

indicator. Also the arrows orientations on the engine anti-ice valve are not in conformity as normally accepted standard. [I suggest] AMM Task should include a view of a manual

override/position indicator for the Engine Anti-Ice Valve and the arrows' orientations Engine Anti-Ice Valve should apply the same standard concept - parallel arrows means

open position and perpendicular arrows means closed position.

Synopsis

A B737NG Mechanic reported he was unable to determine the position of a nose cowl anti-

ice valve in order to defer the valve in the closed position.

ACN: 1381760 (18 of 50)

Time / Day

Date : 201608


Place



Environment

Light : Daylight

Aircraft


Make Model Name : EMB ERJ 170/175 ER/LR Operating Under FAR Part : Part 121



Component

Aircraft Component : Hydraulic Auxiliary System Ram Air Turbine (RAT)



Person

Reference : 1

Location Of Person : Hangar / Base Reporter Organization : Air Carrier


Qualification.Maintenance : Airframe


Human Factors : Situational Awareness Analyst Callback : Completed

Events

Anomaly.Aircraft Equipment Problem : Less Severe Detector.Person : Maintenance



Assessments


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

Narrative: 1

I was observing a maintenance task as required per an audit. The morning the event occurred an aircraft was in the hangar for a routine task. The mechanics were performing

a task to lubricate the Ram Air Turbine (RAT) and, once complete, re-stow the RAT into its fix and locked location. During the re-stow, the inspector is located on the forward side of

the RAT rear facing. Mechanic #1 is located on the aft side of the RAT forward facing, and

mechanic #2 is in the nose wheel well facing E2. Before the procedure began, the inspector did a paperwork review and a general visual inspection of the affected area.

Mechanic #1 was holding the release pin so as the RAT could be unlocked to re-stow. Mechanic #2 was informed that the manual pumping procedure could begin. As the RAT

ascended, Mechanic #1 rotated the RAT and an audible click was heard and he confirmed to the Inspector that the RAT was locked into the correct position for stowing. The RAT

continued to rise into position, once the forward blade was very close to making contact with the airframe the auditor verbally warned that it was going to make contact, but it was

too late and the blade contacted the airframe damaging both.

The cause of the event is that the RAT was not in the correct and locked position. The

mechanic rotated the RAT blades and both he and the inspector heard an audible click, but it was never verified that the lock pin was located in the corrected position.

[Suggest] more instructions and detail in the job cards that inform the users of the

importance of ensuring that the lock pin is in the correct location. An alert to all mechanics and inspectors to be aware of this situation, and a training video of the correct procedure.

Callback: 1

The reporter stated the RAT (Ram Air Turbine) blades were not aligned prior to stowing

during a maintenance procedure causing damage to the RAT blades and dented the aircraft fuselage. The reporter stated that due to this incident the procedures for stowing

the RAT have been changed. The reporter also stated this is not an isolated incident, this has happened several times on the ERJ-170.

Synopsis

Maintenance Technician reported that while attempting to stow a Ram Air Turbine (RAT) on an ERJ-170, the blades were misaligned causing damage to the blades and the aircraft.

ACN: 1380702 (19 of 50)

Time / Day

Date : 201608


Place



Aircraft


Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil


Maintenance Status.Maintenance Deferred : Y Maintenance Status.Released For Service : Y

Maintenance Status.Maintenance Items Involved : Testing Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Turbine Engine

Manufacturer : Turbomeca Aircraft Reference : X

Person


Reporter Organization : Air Taxi Function.Maintenance : Lead Technician

Qualification.Maintenance : Inspection Authority Experience.Maintenance.Lead Technician : 20



Events


Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Maintenance



Assessments



Narrative: 1

This helicopter is used as an electronic news gathering ship. Every 100 hours an engine oil

sample is taken for analysis. During the past four samples, the iron content has spiked. After the initial report was received the manufactures tech rep was advised and sent the

report. His recommendation was to decrease the oil change interval to 200 hours from 300 hours to lessen the amount of contamination passing through the engine. At that time, the

sample level (4.0 parts per million) was less than the threshold level of 7.5 ppm requiring a maintenance action. The next sample was at 8.0 ppm and the maintenance manual calls

for three daily samples to establish the accumulation rate. This requirement was added to the aircraft status sheet which is reviewed by the flight crew's daily and the director of

maintenance (DOM) was advised. The three samples were completely ignored and the

aircraft continued in service. At the next 100 hour, the soap sample results had the iron content at 8.7 ppm. The oil was changed but no other actions were taken. I was away

from the shop for two weeks and upon my return, no other maintenance or sampling had taken place. I asked the DOM to have a tech take a sample and it was sent out. The

sample returned at 91 hours on the fresh oil with an iron level of 8.2 ppm. The manufactures rep was again contacted and he stated that if any fuzz or sludge was

present on the engine chip plugs, the engine should be taken out of service. This was communicated verbally and by email to the DOM. A shop technician stated that there had

been sludge present at the last chip plug inspection and this was ignored by the DOM.

The wear within the engine had increased. Again the proper procedure was to initiate a

three consecutive sampling program but this was not done per the DOM. Instead the oil was changed. At the next sample with fresh oil, the iron level was 9.8 ppm with 81 hours

of operating time. I advised the DOM to take the helicopter out of service but he stated to keep it in service and do another oil change and sample at the next 100 hour.

The engine has a total time of 3400 hours since new with a TBO of 3600 hours. The reason

given by the DOM was a replacement engine was not available for 30 days.

The engine removal level is anything greater or equal to 15 ppm, or an accumulation rate

of greater than .5 mg / hr. These engines have a documented failure rate of certain accessory gears and the tech rep stated that is probably where the iron is being generated

from. The prudent action would be to remove the engine from service prior to TBO and have the problem investigated. Due to management's desire to satisfy contract obligations

with the T.V. station, they have elected to keep the aircraft in service. At the last inspection, there were numerous cracks in the engine firewall which required replacement

indicating a possible engine vibration problem. The information and signs are in place of a

future failure and management continues to ignore the warning signs. This is a precursor to an accident and it will be obvious to any investigating authority there was a known

problem and management chose to do nothing about it.

Synopsis

A Lead Technician reported that the iron content in the oil system of the engine in a

Eurocopter AS350B2 was beyond factory recommended specifications.

ACN: 1380317 (20 of 50)

Time / Day

Date : 201608


Place



Environment

Light : Daylight

Aircraft


Make Model Name : B777-200 Operating Under FAR Part : Part 121


Person : 1

Reference : 1





Human Factors : Training / Qualification Human Factors : Communication Breakdown


Person : 2

Reference : 2

Location Of Person.Aircraft : X Location In Aircraft : Flight Deck

Reporter Organization : Air Carrier Function.Maintenance : Technician



Human Factors : Communication Breakdown Human Factors : Situational Awareness

Human Factors : Training / Qualification Communication Breakdown.Party1 : Maintenance


Person : 3

Reference : 3





Human Factors : Communication Breakdown


Person : 4

Reference : 4 Location Of Person.Aircraft : X







Events





Assessments

Contributing Factors / Situations : Manuals


Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Human Factors Primary Problem : Procedure

Narrative: 1

I was assigned to #1 engine's wash. I hand washed the fan blades. The engine started turning for engine wash. The fan pulled the strap away from attached point. I signaled to

stop the engine. I saw the rail on the ground at my left hand side and strap on the blades.

Narrative: 2

We were assigned to an engine wash on number 1 engine. I helped getting items for the preparation. My assignment was to dry motor the engine. We did the alternate method on

the card which we have not done before. The reason was we did not have the box needed

to do the preferred method. As we were starting to dry motor the engine the person outside told me to stop the engine because of a problem outside by the engine.

We were told to use an alternate method because we didn't have the box to use for the

preferred. Because of that the blades were turning instead of wind milling which in turn caused the accident.

We need to not do the alternate method until the paperwork is changed. Also, buy more

equipment to do the preferred method.

Narrative: 3

While supporting other AMTs in performing an alternate engine wash method on a B777 #1 ENG, the strap attached to the work stand broke loose and damaged the #1 engine

inlet and blades. None of the AMTs involved in preforming this engine wash had never used the alternate wash method before. The paperwork is insufficient pertaining to the

tying off of the fan blades to prevent windmilling or movement. I believe the paperwork should be reviewed and possibly changed. The paperwork should be more specific about

securing the low pressure compressor for the engine wash portion. Add a task line to

instruct securing of the fan blades.

Narrative: 4

I was assigned to do a #1 engine wash on a B777. I along with the other employees

involved opened the engine cowlings. I hand washed the fan blades, then washed up and took a break. Upon end of break I and another AMT went inside the aircraft. I began the

VSV test by beginning to do the test procedures as part of the assigned engine wash. After some time an AMT gave the sign to begin dry motoring. Within approximately 15-20

seconds, a stop the motor signal was given. Within less than a minute I exited the L-1 door and saw the engine spooling down and something yellow stuck in the fan blade ends.

After it stopped I saw the yellow object was a tie down strap.

I believe the event occurred because the employees assigned were unfamiliar with

alternate method of doing the assigned task. The normal procedure required a test box that was unavailable, and the procedure for doing the task with an alternate method was

not clearly spelled out. The normal procedure and the alternate procedure deviated causing confusion and created a more stressful situation on an otherwise normal

procedure. [This] is a potentially dangerous work assignment due to being in the intake of a spinning turbine engine.

I believe that there should be some kind of training program associated with tasks that can be potentially injurious to personnel and so destructive to an engine in such a short

amount of time.

Synopsis

While several Maintenance personnel were performing an engine wash on a B777, there

was a lack of communication between the personnel hand washing the engine fan blades with a blade lock strap in place and the personnel in the cockpit accomplishing an

alternate method by motoring the engine.

ACN: 1379953 (21 of 50)

Time / Day

Date : 201608


Place



Environment

Work Environment Factor : Poor Lighting

Aircraft


Make Model Name : A320 Operating Under FAR Part : Part 121


Maintenance Status.Maintenance Type : Unscheduled Maintenance Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Indicating and Warning - Air Conditioning and Press.



Person

Reference : 1






Events


Anomaly.Deviation - Procedural : MEL Anomaly.Deviation - Procedural : Maintenance


Result.General : Maintenance Action Result.General : Flight Cancelled / Delayed

Assessments


Contributing Factors / Situations : Human Factors Contributing Factors / Situations : MEL


Narrative: 1

I worked Aircraft X at the south end of ZZZ airport. There was little airport lighting in the area at that time. I worked MEL 21-7. Vent avionics sys fault. Changed the skin air outlet

valve ended up being no fix. Per MEL procedures I deactivated the valve in the closed

position with the internal flap in the open position per Aircraft Maintenance Manual (AMM). But it was hard to tell the difference between when the valve is in the closed position and

the internal flap is in the open to 45 degrees position and there was also no amber xxx on cabin pressure page with deactivation switch in the off position during FR EVAC procedure.

Lack of knowledge of how exactly the valve was supposed to respond after complying with

AMM. It was also hard to verify the difference between where the valve is in the closed position and the internal flap is in the open to 45 degrees position. There was absolutely

no way to physically verify that the position of the valve was completely closed and locked

other than press on it. Which all would do would be seat it in place. Pushing on the valve would only seat it back in place with no slack or movement to help with the verification.

Even physically verifying the flap 45 degrees to open was physically impossible. The difference of when the smaller flap open to when the larger flap closes was by turning a

lever and back it off. It does not move then backing it off to store the lever in the flush position. Lack of knowledge to document reactivate and deactivation of valve per MEL 21-7

on log page or non-routine which was all just lack of knowledge.

Lack of resources. I was working remotely from the south end of the airport without a

computer to verify my work and lack of proper lighting for verification process.

Stress because of these factors plus pressure management to clear MEL.

Add to the MEL FR process to visual check the skin air valve is in the full close position, flush fuselage skin.

Synopsis

An A320 Mechanic reported being unable to clear an MEL item, and then improperly re-deferring the valve due to time pressure and inexperience.

ACN: 1379373 (22 of 50)

Time / Day

Date : 201607


Place



Aircraft




Component

Aircraft Component : Wheel Assemblies Manufacturer : Boeing


Person

Reference : 1




Events


Anomaly.Deviation - Procedural : Maintenance

Detector.Person : Maintenance Result.General : Maintenance Action

Assessments


Narrative: 1

I was made aware this morning that I was involved in a maintenance event on Aircraft X. Myself and another Aircraft Maintenance Technician (AMT) were assigned to help another

AMT on a tire change. When asked what we needed to bring he said, the normal

equipment for a tire change and a tablet was onsite. When myself and the other AMT arrived, we changed the tire just like any other tire change. I have since been informed

that myself or the other AMT mistakenly did not install the tab washer.

During the process of this job, and doing repetitive maintenance, somehow the tab washer

was missed upon installation.

Reading the Maintenance Manual verbatim to avoid missing something due to repetitive action of an item that I am comfortable doing. Better communication between co-workers.

Synopsis

Mechanic reported on a B737-800, when replacing a tire, he neglected to install the tab washer.

ACN: 1379368 (23 of 50)

Time / Day

Date : 201608

Place


Aircraft

Reference : X

Aircraft Operator : Air Carrier Make Model Name : B757-200


Maintenance Status.Maintenance Type : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Work Cards

Component

Aircraft Component : Wing Access Panel


Person





Events



When Detected : Pre-flight


Assessments



Narrative: 1

I was performing a LS4 leading edge lube on Aircraft X. I inadvertently did not install five of the six screws in a leading edge panel I removed to lube slat tracks. The panel

remained on the aircraft during flight. Panel was found loose in ZZZ during crew walk

around.

Synopsis

Maintenance reported that on a B757 when installing the access panel for the leading edge

slat tracks the mechanic neglected to install five of the six screws required to secure the panel.

ACN: 1378169 (24 of 50)

Time / Day

Date : 201608


Place



Aircraft


Make Model Name : EMB ERJ 145 ER/LR


Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Trailing Edge Flap Manufacturer : Embraer



Person : 1

Reference : 1





Person : 2






Events






Assessments



Narrative: 1

At the beginning of our shift [co-worker] and I took over the flap fail message on Aircraft

X. We started a zero rig procedure using the Aircraft Maintenance Manual (AMM). While we were raising the flaps and they were at about the zero position there was a sudden noise

from both flaps. When I looked at all of the flaps I found damage to both inboard flaps.

We found that in a caution note the AMM mentions removal of a bracket, however this IS NOT a step in the task, there is also no step to reinstall the removed bracket at the end of

the task.

This bracket removal should be a separate step IN THE TASK and not simply an added

"caution". There should also be a step for REINSTALLING the removed bracket.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

Maintenance personnel reported when performing a "Zero Rig" procedure on the trailing edge flaps on a Embraer 145, they neglected to remove a fairing bracket causing damage

to both inboard flaps.

ACN: 1377686 (25 of 50)

Time / Day

Date : 201608


Place



Environment

Light : Daylight

Aircraft

Reference : X Make Model Name : Helicopter


Maintenance Status.Records Complete : N Maintenance Status.Maintenance Items Involved : Work Cards


Person

Reference : 1

Location Of Person : Hangar / Base

Reporter Organization : FBO Function.Maintenance : Inspector

Qualification.Maintenance : Inspection Authority Experience.Maintenance.Inspector : 20


Events


Anomaly.Deviation - Procedural : FAR



Assessments



Narrative: 1

I started receiving text messages from our repair station concerning an aircraft that had

been in a prior ground accident. It had been in storage outside the maintenance hangar. Pictures showed the aircraft being disassembled. I replied to the lead technician that all

parts removed needed to be documented on the work order with part numbers, serial numbers and disposition. Upon my return, I found the helicopter completely stripped of all

removable items. I located the work order book and there were no completed entries

concerning the removal or identification of any components. Five items were entered as removed for service on another aircraft in the discrepancy block by the director of

maintenance, but no part numbers, serial numbers, component times, or reference for hidden damage inspections were recorded in the corrective action block and no initials or

inspector sign offs. There were no references to the maintenance manuals for component removal and any required inspections either. The repair station manual outlines proper

procedures for work order form completion, procedures for identifying removed components with tags and instructions for performing hidden damage inspections and

proper storage. Not one of these procedures was followed. The current status and location

of the removed components has not been disclosed as they are no longer located with the repair station area.

Synopsis

A Maintenance Inspector reported that someone from his operation had removed parts from an accident aircraft without proper documentation.

ACN: 1376697 (26 of 50)

Time / Day

Date : 201607


Place



Environment

Light : Night

Aircraft


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


Component

Aircraft Component : Air Conditioning and Pressurization Pack Manufacturer : Boeing


Person : 1


Location In Aircraft : Flight Deck




Person : 2


Location In Aircraft : Flight Deck





Events


Anomaly.Deviation - Procedural : MEL Detector.Person : Maintenance

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

Assessments


Contributing Factors / Situations : MEL Primary Problem : MEL

Narrative: 1

I received a call from [a Maintenance Technician]. He explained that the airplane was at departure time and that an issue which had occurred previously had re-occurred. He

mentioned that both the Overhead "PACK OFF" light and the EICAS message for RH PACK were showing. He suggested that we defer the item per MEL. I read through the MEL and

agreed that it was an allowable deferral. I remember checking the existing MELs boarded

on [the aircraft] to verify that all of the components listed in the MEL were operational, and [the technician] agreed that they were. Therefore at this point there was no reason for

me to NOT issue the MEL.

Subsequent to the Flight Crew's needing to don O2 masks and operate the RH Pack in spite of the MEL, it was discovered that both the Avionics Supply Fan and Exhaust Fan had

suffered considerable FOD (Foreign Object Debris) to the fan impellers.

On the 767, the Air Conditioning Packs and the Equipment Cooling systems are separate

and independent. Failure of the Pack and failure of both of the Fans at approximately the same time appears to be coincidental. There was history for FWD EQUIP OVHT, and the

crew had performed a BTB (Bus Tie Breaker), but that issue had been signed off as an intermittent fault. The airplane had performed 3 flight legs without another FWD EQUIP

OVHT message. The RH "PACK OFF" issue was addressed by replacement of the Flow Control Valve.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

Maintenance technicians reported deferring the right air-conditioning pack on a B767-300 and that an equipment cooling system failure on the subsequent flight led to the flight

crew donning oxygen masks and using the deferred pack.

ACN: 1376422 (27 of 50)

Time / Day

Date : 201607

Place

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


Environment

Work Environment Factor : Poor Lighting

Aircraft

Reference : X

Aircraft Operator : Personal Make Model Name : SR22

Operating Under FAR Part : Part 91 Mission : Personal


Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Items Involved : Installation

Component

Aircraft Component : Powerplant Fuel Distribution


Person


Reporter Organization : Personal Function.Maintenance : Technician


Qualification.Maintenance : Airframe Experience.Maintenance.Lead Technician : 3

Experience.Maintenance.Technician : 12 ASRS Report Number.Accession Number : 1376422


Events

Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy

When Detected.Other

Assessments



Narrative: 1

I believe that my training played a part. I have been an A&P for years, but all of that is on corporate aircraft not piston. Also I believe the biggest factor is I did not remove the fuel

pump so when I went to install the pump it appeared to me that the drain line could only be installed on the forward sided so that was the [way] it was positioned in the aircraft. It

would have been nice if the inline and outline were two different sizes and if the

Maintenance manual was a little clearer about the installation of the pump.

Synopsis

A maintenance technician reported incorrectly installing the fuel pump on a Cirrus SR22

aircraft.

ACN: 1376299 (28 of 50)

Time / Day

Date : 201607


Place



Aircraft


Make Model Name : B787 Dreamliner Undifferentiated or Other Model


Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Testing

Component

Aircraft Component : Fan Reverser Manufacturer : General Electric



Person

Reference : 1

Location Of Person : Company Location In Aircraft : Flight Deck

Reporter Organization : Air Carrier Function.Maintenance : Lead Technician


Human Factors : Confusion


Events




Assessments



Narrative: 1

I was assigned to run the engines on aircraft for the operational check-out for the engine

thrust control module. Per the Aircraft Maintenance Manual (AMM) task for installation it required me to perform an operational check of the Thrust Reversers (TR) with the engines

running per [our Aircraft Maintenance Manual reference A]. This reference told me to start the engines per AMM tasks, (Engine operation - Safety Precautions), and [AMM reference],

(Start the Engines - Operation). Prior to starting the engines I reviewed all the AMM references looking for steps, cautions, and warnings that pertained to operating the

engines in reverse. After reviewing I determined that there was only 1 warning and 1 step in the safety precautions task and 2 steps in the TR operational check-out that gave me

any information about the operation of the engine in reverse. The warning out of the

safety procedures told me to keep all people and equipment out of the fan air path when the TR operates due to possible injuries to personnel or damage to equipment from the

high volume of fan air coming out during reverse. The step out of the safety procedures told me that I could run the engine in reverse for maintenance with the aircraft parked and

the engine in idle. The 2 steps out of the TR check-out task told me to move the thrust lever up and aft until the interlock position and make sure not to move the thrust lever off

the idle position. There were no other steps or warnings that I found in any of the tasks that were noted for this check-out.

I proceeded to the aircraft to do my normal pre-engine start walk around and noticed how close the #1 engine was to the jet bridge. I looked thru the safety precautions for a

definition of the inlet hazard area with the engine in reverse but there were only illustrations for the inlet hazard area in forward thrust. Using these as a minimum I felt

that the jet bridge was to close and contacted management to have the bridge pulled off the aircraft. I also had a pre-run conference with the ground crew to notify them that we

were going into reverse and to watch the jet blast. I notified the mechanic standing at the nose about the warning out of the safety precautions and we decided it would be best if he

moved to the opposite side away from the motor that was going into reverse. After this

was completed I went into the aircraft and the jet bridge was pulled as far forward and outboard of the #1 engine as it could be moved. The normal start procedures were used to

start both engines in preparation for the ops check of the thrust reverser. Once the engines were up and running I went thru the procedures for the operational check-out

steps 1(A) and (B) for engine 1 with no issues and then I went to move the TR handle per step 1(C) thinking that I just needed to pull the TR lever back to the first detent and not

advance the throttles off of idle. When I deployed the TR I pulled up and aft and with what I felt was very little resistance the lever moved thru the interlock position to what I

eventually determined was max reverse. The throttles never left the stops and the engine

rapidly advanced thru 76% N2 before I was able to re-stow the TR. The aircraft nose jumped up and the aircraft swung side to side moving what felt like 3 feet left to right, If

there hadn't have been 167,000 LBS of fuel still on board, or the jet bridge had not been repositioned I believe there would have been serious damage to both the aircraft and the

jet bridge. Also if the mechanic standing ground was in the air path of that engine when it went to max reverse he could have been seriously injured.

When I read the step that told me not to advance the engine throttles off of idle I was

under the impression that if I didn't move the throttles forward off of idle, that the engine

would stay at idle in reverse. I now understand that all I have to do is extend the reverser lever to the full travel and I will advance the engine to 80% N2 with no movement of the

throttle. There should be a note or warning letting the mechanics know that there is no mechanical detent to stop them at the interlock position only a resistance of approximately

35 FT LBS to identify the interlock position and if you pull the lever past the interlock position you will take the engine to max reverse without advancing the throttles. Also

there should be an illustration for the inlet and exhaust hazard areas for the engines

included in the safety precautions task of the AMM.

Synopsis

When maintenance performed a Reverser Operational Check on a B787-8 Aircraft in the

terminal area, the Technician exceeded the reverse thrust idle position causing the engine to exceed the thrust limit for the check.

ACN: 1375119 (29 of 50)

Time / Day

Date : 201607


Place



Aircraft


Make Model Name : MD-82




Component

Aircraft Component : Fuselage Main Frame

Manufacturer : McDonnell Douglas


Person


Reporter Organization : Air Carrier Function.Maintenance : Other / Unknown




Events


Anomaly.Deviation - Procedural : Other / Unknown Detector.Person : Maintenance


Assessments


Contributing Factors / Situations : Procedure Primary Problem : Ambiguous

Narrative: 1

Aircraft landed at ZZZ, Removed from service. While the Aircraft Maintenance Technicians

(AMTs) were servicing the hydraulic system they found a crack on the frame of the LH Wheel well area and had QC do a High Frequency Eddy Current (HFEC) to verify the crack.

The crack went from 1 fastener hole to another fastener hole and did not go past either hole. I called ZZZ Flight Operations Engineer about this item to research this crack to see

if an Engineering Authorization (EA) was required. I sent him pictures of the frame crack. He referred me to Initial Operational Capability (IOC) Engineering, I called IOC

Engineering and asked but he was busy working another aircraft. [Another engineer] was available, I told him what I had on [the] Aircraft, a 1.5 inch crack on wheel well frame and

QC accomplished a HFEC and the crack went from fastener hole to fastener hole. I sent

him the pictures of the frame that was cracked and asked him to look at it to see if an EA is needed due to it states to stop drill the end of the crack; but the crack terminated at the

fastener holes and was verified by HFEC. I asked him to review the Maintenance Manual/ SRM Refs 53-10-00-13 and 51-01-00-001. After he reviewed the pictures and the

references, he called back and stated it's still allowable per 53-10-00-13 FOR 25 Flight hours for the channel MPN 5930584-123 and is Ref in Maintenance Manual. MD80

maintenance center was called and item was made for daily inspection and perm repair in 25 flight hours. Aircraft was returned to service.

[The next day], I was reviewing the ZZZ Remain Overnight (RON) BOW and saw that [the same] aircraft was terminating in ZZZ that night and called the Production Control Group

at the hangar, I told them about the frame crack and the 25 flight hours before perm repair needs to accomplished. We talked about the repair adding the doubler takes about 6

hours to complete since have I done about 20 repairs as an AMT. We set it up to go to the hangar for repair and next to sheet metal shop. Next thing that transpired, I received a

call from IOC Manager stating we were stopping [the] aircraft for an ASAP Item. I told him what I knew about this aircraft and had it scheduled to go to the hangar on the RON

tonight, I removed this aircraft from service and on the Pull List to go to the hangar. I

called my Senior Manager gave him the details and all the resources used on this aircraft frame crack.

Synopsis

An Aircraft Maintenance Technician working on an MD82 reported finding a 1 and 1/2 inch crack on the frame of the Left Hand wheel well that went from one rivet to another rivet .

ACN: 1373778 (30 of 50)

Time / Day

Date : 201607


Place



Environment

Light : Daylight

Aircraft


Make Model Name : EC135 Operating Under FAR Part : Part 135


Person

Reference : 1

Location Of Person : Hangar / Base Reporter Organization : Contracted Service




Events





Assessments

Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Logbook Entry


Narrative: 1

After discussion with my area supervisor and my site lead, we decided that a Service

Difficulty Report (SDR) would be applicable for a crack found on an EC135 helicopter during a recent inspection. Aircraft was released for service and the SDR was submitted

the next day however the original discrepancy was dated [almost a month prior]. This resulted in a delayed submittal of the SDR based on the discrepancy date as directed by

14 CFR 135.415 Para. (d)

Avoiding the recurrence of delayed submittal of a SDR during maintenance may be

avoided by a better understanding or greater clarification of the specific requirements needed for submittal. It was unclear whether this item fell under 14 CFR 135.415 Para.

A(14) Aircraft structure that requires major repair; or Para. A(15) Cracks, permanent deformation, or corrosion of aircraft structures, if more than the maximum acceptable to

the manufacturer or the FAA, if any. This could be clarified by the engineering department as they evaluated the discrepancy to determine its severity. Upon discovering that this

discrepancy fell under any of the reportable requirements, it may be suggested (along with

the instructions needed for repair or mitigating the discrepancy) that an SDR was needed to be submitted within the proper time constraints. It should be emphasized that items

found under 14 CFR 135.415 even during extended maintenance have a time restraint of 24 hours from the date of discovery.

Synopsis

Maintenance Technician reported that a Service Difficulty Report (SDR) was submitted for a crack found on an EC135 helicopter nearly a month after discovery due to the

assessment of the condition.

ACN: 1373252 (31 of 50)

Time / Day

Date : 201607


Place



Environment

Light : Daylight

Aircraft


Make Model Name : Widebody, Low Wing, 2 Turbojet Eng Crew Size.Number Of Crew : 2



Person

Reference : 1

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



Human Factors : Situational Awareness Human Factors : Confusion

Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown



Assessments

Contributing Factors / Situations : Environment - Non Weather Related Contributing Factors / Situations : Human Factors


Primary Problem : Environment - Non Weather Related

Narrative: 1

With the advent of Zika virus, a safety concern has been brought to my attention as it

relates to company policies, our deferral process, and/or handling of situations surrounding mosquitos and health issues surrounding them. [An aircraft] arrived from

Buenos Aires. The aircraft had a write up of, "in excess of 30 mosquitos throughout the cabin." There was also a note stating that it had been cleaned on a hardstand in Buenos

Aires with cabin doors open. There were 2 issues with this. The first is [a maintenance directive] item was issued for insect service (instead of being fumigated immediately) and

secondly the work has still not been accomplished. With all the information of Zika virus coming out of South America, wouldn't it be prudent to take care of this immediately

instead of exposing our employees and customers to a possible known virus?

Synopsis

An air carrier Maintenance Technician reported a health and safety concern over a delay in addressing mosquitos in the cabin after a flight from Buenos Aires.

ACN: 1371812 (32 of 50)

Time / Day

Date : 201607

Place



Aircraft

Reference : X

Aircraft Operator : Air Carrier Make Model Name : B747 Undifferentiated or Other Model

Operating Under FAR Part : Part 121


Component

Aircraft Component : Aircraft Auto Temperature System Aircraft Reference : X

Person




Human Factors : Other / Unknown Human Factors : Communication Breakdown

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

Events


Anomaly.Deviation - Procedural : MEL Detector.Person : Flight Crew

When Detected : Pre-flight Result.General : Maintenance Action

Assessments

Contributing Factors / Situations : MEL Primary Problem : MEL

Narrative: 1

The flight crew called and were concerned that a deferred item on their MRD did not reflect

what part of the system was on MEL.

Below is the text as it appears: Pack EICAS status message displayed. Neither PTC in control of pack 1 or pack component

failure or overheat or pack trip due to overheat or out of sequence. Pack 1 status message

reset 3 times by mechanics keeps coming back.

This is the text as it appears on the MRD. It does not show what system is actually on MEL. It shows at the bottom of the write up that Pack 1 Channel A is inop. This should

show up on the MRD.

On the MRD it shows the Placard 2126s but it gives no description of what this particular placard is, IE Pack 1 Channel A.

See MEL below. Pack temperature control systems.

Spec notes: one pack temperature controller (A or B) may be inoperative for each operating pack. Maintenance: Install deferred no. Decal adjacent to associated pack

control selector on the P5 overhead panel.

This lack of information on the MRD for our flight crew is going to and has already caused confusion. This could also lead to a flight crew possibly configuring the flight deck

incorrectly since the inop system is not being identified correctly.

Synopsis

The Maintenance Release Document on a B747 did not reflect which part of the Air Conditioning system was deferred.

ACN: 1371019 (33 of 50)

Time / Day

Date : 201607


Place



Aircraft





Component

Aircraft Component : Main Gear Tire


Person

Reference : 1




Human Factors : Situational Awareness Human Factors : Time Pressure

Human Factors : Communication Breakdown


Events


Anomaly.Ground Event / Encounter : Other / Unknown Detector.Person : Maintenance



Assessments





Narrative: 1

[A coworker] and myself were taken to taxi aircraft from gate. On my pre-Taxi walk

around I found number 2 MLG tire underinflated. I told [coworker] I would address it accordingly. I called terminal maintenance and I requested that they send out a mechanic

to verify tire pressure. A mechanic whom I don't know took the pressure and stated it was only 60psi. [A coworker] went down and said he wanted to re-service the tire to service

limits. [Another coworker] said that was against General Procedures Manual (GPM) and

unsafe and that both tires should be changed. I called Tech and spoke with them on the desk to see what my options were. They also stated that both tires had to be changed.

When I went from the cockpit to tell the mechanics this I discovered that they had re-inflated the tire to service limits. I [told] them both (Whom I don't know their name) that

now they had as "BOMB". I asked them why they would do that and they stated they were told to do so. I called and explained what occurred and requested to be reassigned to a

different aircraft. Upon pushback the No.2 tire which was re-inflated to service limits exploded after just moving a few feet.

This occurred because of the management's insistence that the aircraft is to be removed off the gate at all cost to prevent delays.

This was an easy fix.

GPM states that if one tire is below limits both tires should be removed and replaced..

PERIOD

Why is this type of disregard for policies and procedures that we have in place for

retention of our operating certificate from the FAA be so disregarded for the profitability of the shareholders and upper management is a recipe for the ultimate betrayal for the

common employee let alone the passengers if the exploding tire killed the mechanic servicing it could be called justified...if the exploding tire killed another mechanic it would

have been homicide...

Synopsis

On a B737-800 a #2 Main Landing Gear tire exploded because it was found underinflated

and it was inflated instead of following the maintenance manual which required replacement both #1 and #2 tires.

ACN: 1370905 (34 of 50)

Time / Day

Date : 201607

Place


Aircraft

Reference : X

Aircraft Operator : Air Carrier Make Model Name : Commercial Fixed Wing


Component


Person

Reference : 1 Location Of Person : Gate / Ramp / Line

Reporter Organization : Air Carrier Function.Ground Personnel : Other / Unknown


Events


Anomaly.Ground Event / Encounter : Other / Unknown Detector.Person : Other Person


Assessments


Narrative: 1

Aircraft was pushed off the gate. Had to be towed back into gate due to engine problem.

All wheels were chocked. (10 chocks). Mechanics told me they wanted to start #2 engine on the gate. We started to pull main chocks as I assumed we would push after engine

start. Mechanics told me to leave the chocks in because they would shut it down.

Mechanics got the engine started. After it ran for a minute or two, two mechanics walked around the left side of the airplane, then crawled underneath the plane and pulled main

while chocks while engine was still running.

Synopsis

A ramp service employee reported that while mechanics were running the engines on an aircraft, two other mechanics crawled under the aircraft and pulled the chocks.

ACN: 1370601 (35 of 50)

Time / Day

Date : 201607


Place



Environment

Light : Dawn

Aircraft


Make Model Name : B737-900 Crew Size.Number Of Crew : 2



Maintenance Status.Maintenance Deferred : Y

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


Component

Aircraft Component : Cargo Compartment Sidewall Panel


Person

Reference : 1




Events


Anomaly.Deviation - Procedural : Maintenance Anomaly.Deviation - Procedural : FAR

Detector.Person : Maintenance Detector.Person : Ground Personnel



Assessments

Contributing Factors / Situations : Aircraft Contributing Factors / Situations : MEL

Primary Problem : Aircraft

Narrative: 1

[Maintenance technicians were] dispatched to aircraft to evaluate damage to the sidewall

liners in the aft pit R/H side. We found unserviceable liners based on AMM 25-52-01 (holes

larger than 1.5"). This is not the first aircraft in the last two weeks that had to have MEL applied due to excessive damage to the sidewall liners. The damage appears to be frame

by frame progressive over time. The question is, when is it now unserviceable and when does the ramp decide it's time to call it in? It seems these holes are out of limits long

before the call is made. That would be an unsatisfactory condition for flight based on AMM 25-52-01, FAR 25.855 and FAR 25.853. Two more aircraft come to mind that I was

involved with in the last two weeks. These also required MEL in order to release the aircraft. Both had damaged R/H sidewall liner damage that appears to be progressive.

Normal wear with lack of aggressive inspection intervals

Increase inspection intervals by Mechanics. Educate Ramp. Apply a strip of "Pile Velco"

(sticky back) to the rivets on each frame where wear occurs. This acts as a barrier between the liner and frame button head rivets. It's these rivets that are wearing through

the liner.

Synopsis

Line Aircraft Technician reported finding excessive damage to cargo pit sidewalls in a

B737-900 due to wear from rivet heads on the frame. He found holes larger than 1.5

inches which exceeded the limit in the FARs.

ACN: 1370016 (36 of 50)

Time / Day

Date : 201606


Place



Aircraft


Make Model Name : Brasilia EMB-120 All Series



Component

Aircraft Component : Microphone Aircraft Reference : X


Person





Events



Detector.Person : Flight Crew When Detected : Aircraft In Service At Gate

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

Assessments


Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part Primary Problem : Ambiguous

Narrative: 1

I was told to install a hot mic switch on the captain's yoke. I gained access to switch and

wires before uninstall I labeled the 3 wires accordingly. Proceeded with the uninstall cut the wires, strip off the insulation and resoldered the 3 wires to the new switch as labeled.

Reinstalled switch on yoke and ops checked it by comparing it with the First Officers's side. Ops check good. Signed it off.

Pilot noticed the switch was upside down.

I just soldered the 2 wires reverse of each other and installed switch upside down, so it

function correctly upside down but right side up it was backwards.

I then reinstalled the switch right side up. Signed it off as flipped switch. Then pilot noticed

the hot mic switch and push to talk was reversed.

Synopsis

A maintenance Technician installed a "Hot Mic" Switch on the captain's yoke upside-down.

ACN: 1369027 (37 of 50)

Time / Day

Date : 201607


Place



Environment

Light : Daylight

Aircraft


Make Model Name : B737 Undifferentiated or Other Model Crew Size.Number Of Crew : 2


Component

Aircraft Component : Cockpit Door Aircraft Reference : X

Problem : Design

Person






Events

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Security



Assessments



Narrative: 1

Noticed today that the 737 fleet (and maybe others) are having the flight deck doors

modified and the flight deck door mechanical lock either covered over or removed, leaving only the electronic means for securing the flight deck door. The problem is when the

aircraft is on Ground Service Bus, the electronic flight deck door lock system is not powered and the flight deck door cannot be secured.

In addition, when the aircraft is powered down, the flight deck door can no longer be

secured mechanically either. Seems an unnecessary security risk, after years of improving security.

Synopsis

Maintenance Technician reported their air carrier's B737 fleet are having flight deck doors

modified with new all electric locking systems. Reporter stated the flight deck doors cannot be secured when the locking systems have no power.

ACN: 1368251 (38 of 50)

Time / Day

Date : 201606


Place


State Reference : US

Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ Aircraft Operator : Air Carrier

Make Model Name : SF 340B Crew Size.Number Of Crew : 2


Mission : Passenger Flight Phase : Initial Climb

Airspace.Class C : ZZZ


Component

Aircraft Component : Nacelle/Pylon Skin Aircraft Reference : X


Person

Reference : 1

Location Of Person : Gate / Ramp / Line




Events


Anomaly.Deviation - Procedural : Maintenance Detector.Person : Flight Crew

When Detected : In-flight

Result.Flight Crew : Returned To Departure Airport Result.Aircraft : Aircraft Damaged

Assessments



Narrative: 1

In between flights I performed the daily oil check on the RH engine. This is done by accessing the outboard door on the #2 engine. I opened the door and installed the stay

arm in the front only to keep it open while I serviced the engine with oil. On the completion of servicing I reinstalled the oil cap and closed the door and latched it closed.

After returning the spent oil can to the truck I came back out to the airplane to grab the

ladder and I reopened the door by accessing the latches and double checked that the oil cap was installed properly. I then closed the door a second time and pushed against it to

ensure the latches were seated properly in the adjacent alignment holes. I then returned the ladder and came in to the office to finish the paperwork and record the amount of oil.

This was at approximately XA:55. The plane departed at approximately XB:20 and shortly after takeoff they contacted the ops phone and said they would be turning back and would

need maintenance when they landed. I immediately went outside and waited. I witnessed them landing and saw the nacelle door open and immediately called my first line

supervisor. This call was made at approximately XB:42 even before the plane finished

taxiing back to the gate. When it got to the gate I immediately recognized that there was damage to the nacelle door and that both locking (latch) hinges were in the locked

position. It is my understanding that the FA saw the nacelle open after takeoff but before 200ft and immediately called the pilots to notify them.

I am baffled as to why this event occurred. I am positive that after having the second

thought to double check the oil cap that I properly seated and latched the nacelle door. Before [my Supervisor] arrived the FO for that flight relayed to me that that was his first

flight of that day and that he did a thorough walk around which included verifying that

both engine nacelles were latched seated and closed. What he described as the "first flight of the day" walk around. I am not sure what the crew did but I think they executed a

pattern and returned to the field without declaring an emergency.

It may be a poor description of how I feel, but again I am baffled because I am positive the nacelle door was latched and closed properly. I don't even know how to speculate as

to how it came open in flight other than the center of the nacelle possibly buckled failed and pulled it out of the alignment holes. I want to add that if I wasn't positive about

latching the nacelle door that I would own it immediately and say so.

Synopsis

A maintenance Technician reported that after accomplishing an oil service on a Saab SF340B, the aircraft departed then returned to the airport due to the oil service door

coming open in flight.

ACN: 1367076 (39 of 50)

Time / Day

Date : 201606

Place



Aircraft

Reference : X

Aircraft Operator : Personal Make Model Name : No Aircraft

Mission : Training

Maintenance Status.Maintenance Deferred : N Maintenance Status.Maintenance Items Involved : Inspection

Maintenance Status.Maintenance Items Involved : Repair Maintenance Status.Maintenance Items Involved : Installation

Component

Aircraft Component : Powerplant Accessory Gearbox

Person

Reference : 1

Reporter Organization : Personal

Function.Maintenance : Lead Technician Qualification.Maintenance : Powerplant

Qualification.Maintenance : Airframe Experience.Maintenance.Inspector : 15

Experience.Maintenance.Lead Technician : 28 ASRS Report Number.Accession Number : 1367076


Communication Breakdown.Party2 : Other

Events



Assessments



Narrative: 1

As reported by a former trainee and my own experiences. During the process of

assembling an Pratt & Whitney PW100 gearbox. During the assembly process of the gearbox,(RGB) the process to assemble the "bullgear" onto the propeller shaft assembly is

very detailed as to the specific tools called out in the repair manuals for this model engine

series. There are special tools called out by part number during the process.

During this process there was a failure of the assembly tool installation due to incorrect pressures being applied to the wrong tooling. The results were the hydraulic ram departed

from the containment ram of 25 lbs to crash down upon the bullgear and the propshaft. After reporting the incident the supervisor was briefed and instructed to repair the gearbox

as. I have been instructed with the same instructions and I was fired for complaining about the very practices.

There is a culture of corruption in place there reporting illegal practices is punished to the point where you either get treated as a "bad employee who HR was already think of

getting rid of", where paperwork will come out of the blue that suddenly produced to say you're not a proper mechanic. There [are] many cases of used uninspected parts being

used to save money through several engine lines. There are many people there too afraid to say anything to keep [their] jobs.

Synopsis

During the process of assembling a Pratt & Whitney PW100 gearbox the incorrect tooling

was used and the incorrect pressure was applied causing the hydraulic ram to depart and crashed onto the bullgear and propeller shaft.

ACN: 1366948 (40 of 50)

Time / Day

Date : 201606


Place



Aircraft


Make Model Name : A321



Component

Aircraft Component : Cargo Door Manufacturer : Airbus



Person

Reference : 1





Analyst Callback : Completed

Events



Assessments

Contributing Factors / Situations : Procedure Contributing Factors / Situations : Aircraft


Narrative: 1

I have been informed by a line cargo safety rep, that they have been told (and he has furnished me with an alert bulletin), that if the cargo compartment doors on the airbus

fleet are inoperative (Hyd system on MEL, and or unable to open), that they are to open

the door manually. This being said, I believe this puts them at danger, and anyone unloading and loading the aircraft in danger, because they do not have access to our AMM

(Aircraft Maintenance Manual) and are not qualified on the aircraft. The AMM is clear on what needs to be done (safety measures, such as writing down the time of opening, and

also installing hold open locks.) I would request that the company would cease (reconsider) this process, in the best (championing) interest of safety for all employees

involved, and also to prevent possible aircraft damage. I have supplied the alert bulletin, as well as the AMM references. Have AMT's open the cargo doors, in case of them not

being operative!

Callback: 1

The reporter stated that this is a SAFETY ISSUE. The reporter stated that when the hydraulic system for the cargo doors is inoperative it requires personnel to follow the

procedure in the AMM by a qualified mechanic. The reporter also stated that contract Maintenance is called on when the Aircraft is at an off line station to perform this task.

When the aircraft is at a maintenance facility and mechanics are available the cargo crew open the cargo door themselves and they are not qualified to do so. The reporter stated

that if the Maintenance Manual is not followed precisely the cargo door can fall and cause

injury.

Synopsis

A maintenance technician reported that non maintenance personnel are hand pumping

open Airbus cargo doors when the hydraulic system for the cargo doors is deferred per the MEL.

ACN: 1366311 (41 of 50)

Time / Day

Date : 201606


Place

State Reference : US


Aircraft

Reference : X

Make Model Name : B737-700 Flight Phase : Parked

Maintenance Status.Maintenance Type : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Testing

Component

Aircraft Component : Flap Fairing



Person : 1

Reference : 1

Location Of Person : Repair Facility





Person : 2






Events


Anomaly.Ground Event / Encounter : Object


When Detected.Other

Assessments


Contributing Factors / Situations : Environment - Non Weather Related Contributing Factors / Situations : Human Factors


Narrative: 1

I was asked by my Co-worker assigned with me to lower flaps for visual inspection and

post dock inspection. I verified with the engine change Crew (also assigned to the aircraft) that it was okay to do so. They confirmed. I looked quickly under both wings for people

and obstructions. There was a wing stand under the left wing. It was not used for our operation. It looked to be in a safe position, however I was mistaken. I completed the

reactivation of hydraulics by removing the hydraulic pump switch guard. I yelled out to the engine change Crew and my Co-worker thru the R-1 door "Hydraulics coming on, Flaps

coming down". My Co-worker echoed "Hydraulics - Flaps". I heard this and thought I was clear to lower flaps, because I heard no other alarms from my Co-worker after he

announced. I pushed the ground call button as a final warning and turned on hydraulics. I

proceeded to lower flaps. As the flaps were lowering I was observing, from the L1 and R1 doors, the progress. From my view things looked okay. As the flaps approached near full

extension @ approximately 30, I heard and felt a crunching sound. I immediately turned off hydraulics. I went down to investigate what happened. The left wing outboard flap

fairing tail cone had crushed into the wing stand. I felt that my Co-worker was observing the overall flap deployment operation. I was wrong. I should have made sure that he was

aware of all things around the aircraft before I operated the flaps. We are normally very careful of these things in the hangar.

Narrative: 2

[Another AMT] and I were on the MV-2 together. [Maintenance Inspector] said lowering

the flaps would not interfere with the engine change. I needed the flaps (lowered) to complete the MV-2 check. I told [Another AMT] that we should lower the slat and flaps.

[Another AMT] went up to the cockpit, I went over to the engine change Crew, asked them if it was ok for hydraulics and to lower slats and flaps, and they said it was ok. The anti-

collision light came on. I did not clear [Another AMT] to lower flaps. I cleared the area around the right wing flaps then went to the E&E compartment to verify that the hydraulic

CBs had been reset. They had not been reset, so I reset them. When I came out of the

E&E compartment I was told of the aircraft damage. I never had the opportunity to clear the left side of the aircraft.

Synopsis

When lowering the flaps during maintenance on a B737-700 the mechanic was unaware of a wing stand under the flap fairing. The left wing outboard flap fairing tail cone crushed

into the wing stand.

ACN: 1366195 (42 of 50)

Time / Day

Date : 201606

Place



Environment

Weather Elements / Visibility : Rain

Aircraft

Reference : X

Aircraft Operator : Air Carrier Make Model Name : Boeing Company Undifferentiated or Other Model


Component

Aircraft Component : Smoke Hood Aircraft Reference : X

Problem : Design Problem : Malfunctioning

Person

Reference : 1






Events




Assessments

Contributing Factors / Situations : Equipment / Tooling

Primary Problem : Equipment / Tooling

Narrative: 1

New aircraft [from delivery from Boeing]. Located at our maintenance facility. During pre-

delivery modifications of aircraft after delivery from Boeing aircraft company. During these modifications, maintenance personnel are advised to remove and destroy as per safety

regulations, the 11 on-board PPE or PBE's (Personnel Breathing Equipment) that came with the aircraft from Boeing, to be replaced with a different style that our company

installs during the pre-delivery of the aircraft. During this destruction of the PBE the maintenance personnel are told to open and then activate the PBE's before disposing of

them locally.

While trying to open the sealed vacuum packing wrap around the PBE, nine (9) times the

handle ripped off without opening the sealed vacuum packaging wrap. Only two (2) times did the handle open the PBE sealed package properly. Maintenance personnel had to use

pocket knives to open the other nine sealed containers that did not open.

Synopsis

A Maintenance Technician reported factory installed PBEs were removed per company

instructions, activated, and then disposed. Nine of the eleven PBE packages that failed during attempted opening were then opened with pocket knives.

ACN: 1366031 (43 of 50)

Time / Day

Date : 201605


Place



Aircraft


Make Model Name : Regional Jet 200 ER/LR (CRJ200)




Person

Reference : 1






Events


Detector.Person : Maintenance Result.General : None Reported / Taken

Assessments



Narrative: 1

This report is not specific to Aircraft X, but instead applies to all aircraft as a safety issue.

Aircraft X was chosen for the aircraft number because it was the latest aircraft involved

with this issue. I was not personally involved in this incident. However, I felt I needed to file a report simply to address this ongoing fleet wide safety issue.

It was brought to my attention that several individuals (myself included) have had safety

concerns with ground pressurization of the aircraft. Ramp personnel have repeatedly

attempted to open doors and servicing ports on the aircraft while the aircraft is being pressurized by maintenance personnel. In the most recent instance, a maintenance ground

spotter was being used, and the beacon light was selected on. A ramp agent rapidly approached the cargo bay while the aircraft was pressurized. Before the maintenance

spotter could stop her, she began attempting to open the cargo door. The spotter immediately stopped the ramp agent. At the same time, the mechanic pressurizing the

aircraft had received a cargo door caution message. The cargo door handle had been extended, but the door was never turned and pressure was never lost. The mechanic in

the cockpit had been in the process of depressurizing when the event occurred, and

continued to bring the delta P back to zero. After the aircraft was depressurized, the mechanic who had been in the cockpit confronted the ramp agent and her supervisor. He

explained that the aircraft was being pressurized and had the beacon light on. He explained that by ignoring the beacon light and attempting to open a door, she

jeopardized her health and safety as well as his. The reaction of the ramp agent and her supervisor was apparently one of non-concern. Neither felt anything that had been done

was dangerous and they tried to make light of the incident.

I suggested the mechanic in the cockpit file a [safety] report on the incident. I am unsure

if [they] followed up or not. I am filing this report because this has been an ongoing problem. Too many close calls have taken place. Luckily, no injuries have yet been

sustained as a result thus far. The ramp personnel (including fuelers) do not respect the beacon light. They routinely drive behind aircraft with the engines running and the beacon

lit. Some time ago I witnessed a lavatory truck being used to service the aircraft while #2 engine was still running. When I warned the individual, they waved me off and didn't seem

to care. Personnel on the ramp also routinely disobey marshaling signals from mechanics warning that engines are running. They have repeatedly attempted to open aircraft doors

while the aircraft is pressurized, beacon on, and spotters present. They do not understand

the concept of pressurization even when warned by mechanics. I feel the ongoing lack of respect for the dangers of aircraft, coupled with lack of adequate training and high

employee turnover, will result in serious injury and/or possible death if things are allowed to continue status quo.

As mechanics, we can only do so much to keep people safe around the aircraft. Perhaps a

change in the manner we perform ground pressurizations is in order. However, without a concurrent change in the safety culture on the ramp personnel side, events like these will

most likely continue to occur. With high employee turnover on the ramp, it is all the more

imperative that aircraft safety be stressed during training.

[Suggest] improved safety training for ramp personnel. Possible procedural changes for maintenance ground pressurization checks.

Synopsis

Air Carrier maintenance Technician reported that while pressurizing an aircraft ground personnel are attempting to open doors and/or service the aircraft ignoring the warning

signs, ie; "beacon light".

ACN: 1363466 (44 of 50)

Time / Day

Date : 201606


Place



Aircraft

Reference : X Aircraft Operator : Corporate

Make Model Name : Falcon 7X



Maintenance Status.Released For Service : Y Maintenance Status.Maintenance Type : Scheduled Maintenance


Person


Reporter Organization : Corporate Function.Flight Crew : Other / Unknown

Function.Maintenance : Other / Unknown Qualification.Flight Crew : Air Transport Pilot (ATP)



Events



Assessments


Narrative: 1

Upon review of logbook entries from a large inspection, it was discovered that a smaller

inspection, which should have been performed at the same time, wasn't accomplished. The aircraft was released for service, dispatched, and flew a trip before the error was

discovered.

There are several factors that led to the error. We don't have a dedicated technician, so as

chief pilot I'm tasked with maintenance planning and control, despite a lack of maintenance experience and knowledge. This will be addressed by using our contract

technician more in the future to review maintenance and documentation before departing from a maintenance center. We put blind faith in the service center, having a false sense

of security from them being a manufacturer service center.

The maintenance manual had been revised in December 2014 to change the frequency of the basic inspection, from 2 months to 300 hours, with the caveat that the basic be done

at the A inspection if 300 flight hours hadn't been reached between two A-inspections. The

service center clearly missed the caveat. However, I knew that the basic had to be done, and as stated above, had blind faith that the basic would be done. This should've been

confirmed with the service center, and will be in the future.

Finally, in the future, I will be more familiar with the maintenance requirements going in, and review the sign-offs before departing maintenance. The basic inspection will be

performed by our contract technician before our next trip.

From the Aircraft Maintenance Manual:

The FALCON 7X maintenance cycle is based on four types of inspections:

Basic inspection: every 300 flight hours,

A inspection: every 600 flight hours or 9 months, whichever is reached first,

The A inspection must be supplemented by the Basic inspection if 300 flight hours haven't

been reached between two A-inspections.

The Basic inspection is a very simple inspection that includes mainly a walk around

inspection, reading of the maintenance messages, and operational checks.

Synopsis

On a Dassault Falcon 7X the basic inspection procedures were not being followed per the

aircraft maintenance manual.

ACN: 1361469 (45 of 50)

Time / Day

Date : 201606


Place



Environment

Light : Daylight

Aircraft

Reference : X Make Model Name : Citation Excel (C560XL)


Flight Plan : IFR Flight Phase : Parked


Component

Aircraft Component : Elevator Trim System


Person



Qualification.Maintenance : Airframe

ASRS Report Number.Accession Number : 1361469 Analyst Callback : Attempted

Events

Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Maintenance

Detector.Person : Maintenance Detector.Person : Flight Crew


Assessments



Narrative: 1

Elevator trim actuator removed per Work Order written up by pilots as binding. It was

found to have internal damage to one externally threaded screw (lollypop) when torn down. The actuator was observed prior to tear down to have a very narrow band of free

movement in both directions then would lock up being impossible to turn by hand. The actuator was damaged internally in a way impossible during service. Proper testing

procedures per the CMM (Component Maintenance Manual) 27-10-01 would have rejected the actuator had they been performed after assembly, also post installation checks per the

AMM (Aircraft Maintenance Manual) would have found this discrepancy had they been followed. I see no way the externally threaded screw (lollypop) could be damaged after

assembly or installation.

Where did this actuator come from? Who built it? Who installed it? Are they aware

manuals are provided for safe servicing and installation of trim tab actuators?

Synopsis

A Mechanic reported that a Cessna 560XL elevator trim actuator was binding and found to

have internal damage.

ACN: 1360166 (46 of 50)

Time / Day

Date : 201606


Place



Aircraft


Make Model Name : Regional Jet 900 (CRJ900)


Flight Phase : Parked Maintenance Status.Maintenance Type : Unscheduled Maintenance


Component

Aircraft Component : Electrical Wiring & Connectors


Problem : Failed

Person

Reference : 1


Function.Maintenance : Technician Function.Maintenance : Lead Technician


Events


Anomaly.Deviation - Procedural : MEL Detector.Person : Maintenance


Assessments



Narrative: 1

Aircraft with MEL 24-11-XX, IDG 1/IDG 1 FEEDER FAULT, 1 Day remaining on MEL. When we opened the LH core cowl, damage was noted to IDG Feeder wires, one feeder wire

burnt half way through. It was noted that an Adel clamp was missing that attaches the feeder harness to engine stand-off bracket and the harness was routed in front of the

remote oil service line when it's supposed to be routed behind the line. Had the harness

been attached with Adel clamp and routed correctly there would be no way for the Feeder cables to chafe. So there is the cause of the damage.

The engine was last replaced [recently with many] Cycles ago. The C2 Task card was last

completed [in previous months.]

Improper routing of phase lead wiring and missing ADEL caused chaffing and eventual arching. This caused a IDG failure.

Synopsis

Mechanic reported that while investigating an MEL item, (IDG FEEDER FAULT) on a CRJ-

900, found damage to the IDG Feeder wires due to a missing clamp.

ACN: 1359419 (47 of 50)

Time / Day

Date : 201605


Place



Aircraft


Make Model Name : Regional Jet 200 ER/LR (CRJ200)


Maintenance Status.Maintenance Type : Scheduled Maintenance Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Main Gear Door Manufacturer : Bombardier



Person : 1

Reference : 1

Location Of Person : Repair Facility Reporter Organization : Air Carrier




Person : 2






Events





Assessments


Contributing Factors / Situations : Manuals Primary Problem : Manuals

Narrative: 1

The Aircraft was in for Service and an A check inspection. The LH MLG (Main Landing Gear) door hinge bushing had been written up for excessive play so the door needed to be

removed for bushing replacement. I went to the aircraft and inspected the LH gear so it

could be retracted to aid in easier removal of the LH MLG door. I called over a technician to assist me by holding the door during retraction. We both looked at the gear linkage and

all the hardware was secure and the bell crank appeared to be in the correct position for gear retraction. The door was disconnected previously at the bellcrank on the door strut

attach side. I went up into the flight deck and powered the aircraft and pressurized hydraulics. I raised the gear handle and the LH gear began to retract. A short time later

before the gear was fully retracted I heard a whistle followed by the technician saying "Gear Down". I immediately returned the gear handle to the down position, waited for the

gear to extend, depressurized the hydraulics and went to investigate the problem. When I

arrived at the LH gear bay we found that the airframe to bellcrank linkage was broken. Upon further investigation we noted that the bellcrank had rotated backwards during

retraction and caused the linkage to break and be pressed up into the up-lock assembly support frame area of the fuselage causing a dent and tear in the structure.

In the maintenance procedure CRJ 200 AMM 32-12-00 for retracting the gear, with the

door disconnected, it states to disconnect the door in the location that the door had been previously disconnected. There is also a caution in the section that states to make sure the

bellcrank is overcenter to avoid damage to the aircraft. Both myself and another technician

looked at the bellcrank and determined that it appeared to be in the correct position for retraction. During the retraction of the gear the bellcrank rotated backwards and caused

the damage to the aircraft explained above.

The Aircraft Maintenance Manual (AMM) needs to be revised showing an image of what you should expect to see for the note that says the bellcrank needs to be overcenter. It

doesn't explain overcenter which way or how it should look overcenter. I don't believe this would have occurred if there would have been a better explanation of which position the

bellcrank should have been in to avoid damage. Both I and the other technician are

experienced mechanics and we both had determined at the time in our best judgment that it was in the correct position for retraction.

Narrative: 2

On the hangar floor, I was asked to assist my coworker in retracting the gear for gear door work. We both observed bellcrank and arm, discussed it and came to the conclusion that

when the gear retracted, we should achieve correct overcenter of the bellcrank and there would be no problem. I held the door open and my coworker put the gear up. All appeared

normal until I heard a snap which was followed by the gear stopping short of being fully

stowed. Blew whistle and yelled for gear down. Gear came down without incident. Then noted broken door arm and damaged airframe.

MLG did not retract completely into the wheel well...

Unfamiliarity with gear door direction of actuation.

Whenever CRJ 200 MLG is retracted with the door disconnected, Door rods and bellcrank should be completely removed for the airframe and gear and left only attached to the gear

door, No room for error if that action is taken.

Synopsis

Two maintenance technicians reported that while retracting the Main Landing Gear on a

Bombardier CRJ200 for maintenance, with the MLG door disconnected, the bellcrank was

out of the proper position causing the linkage to break and damage to the aircraft.

ACN: 1358749 (48 of 50)

Time / Day

Date : 201604

Place



Aircraft

Reference : X

Aircraft Operator : Air Carrier Make Model Name : B777 Undifferentiated or Other Model

Operating Under FAR Part : Part 121


Maintenance Status.Maintenance Items Involved : Installation

Component

Aircraft Component : Engine Pressure Ratio Indicat

Manufacturer : P&W Aircraft Reference : X

Person

Reference : 1





Events

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Maintenance

Detector.Person : Maintenance Result.General : Maintenance Action

Assessments



Narrative: 1

I just became aware of an investigation involving the Number 1 engine on a B777. I assisted with the buildup of the engine after the engine was air shipped. According to the

investigation a B-nut was found loose on one of the PT2 (Pressure Total 2) tube connections.

I was sent to this field service on the red eye to help mechanics with the engine change. We arrived around XA:00 [in the morning]. The engine wasn't scheduled to arrive till the

afternoon. We went to the hotel around XD:00 and returned to the hangar around XJ:00 [in the afternoon] that day. Later that day we helped unload the engine and transport it to

the hangar. We started to build up the engine while still in the shipping stand. I assembled the left side of the fan case and my partner was working on the right hand side. Starting

at the top, I installed everything on the left side down to about 8:00 o'clock position on the fan case where the stand interfered with any further work. The local crew was still

removing the engine from wing. At this point around [XS:00] we went to the hotel and

returned the next morning. Waited till around XK:00 for the crew to hang the new engine. We continued the build as soon as the engine was hung and were able to access the

bottom. The PT2 line in question is made up of three sections. Not all of these sections were disassembled for shipping. Without knowing the exact location of the loose B-nut I

can't say for certain that it was disconnected for shipping. To the best of my knowledge I connected and secured all the lines that were disturbed on the left side. I recall noticing

that not all the PT2 tube B-nuts had provision for safety wire, which was odd since the majority of our PW (Pratt and Whitney) engines PT2 tube connections are safety wired.

There was an aircraft inspector present during this time monitoring and checking the work.

Synopsis

Maintenance Technician reported a PT2 (Pressure Total 2) tube "B" Nut was left loose on a Pratt and Whitney engine for a B777 aircraft.

ACN: 1357713 (49 of 50)

Time / Day

Date : 201605


Place



Aircraft


Make Model Name : B767-300 and 300 ER



Person

Reference : 1





Events


Anomaly.Deviation - Procedural : FAR Detector.Person : Maintenance



Assessments


Contributing Factors / Situations : Procedure Primary Problem : Company Policy

Narrative: 1

While performing the ETOPS walk-around on aircraft, found evidence of hydraulic fluid under belly of aircraft. Opened panel 198CR, found no leaks. Found the inflation system

ramp slide pressure hose Rh side FRAYED braiding, collapse and contaminated.

Researched the Maintenance Manual (MM) procedures which states replacement of the damaged hose (FRAYED braiding). Entered in the Log Book, item was signed off by the

supervisor with an EA (Engineer Authority), written by an Engineer.

We are concerned with the safety and airworthiness of the airplane and the safety of the

passengers. The item in question here is the TESTING that has been performed on the hoses and its passing performance.

How is the Engineer determining the condition of the FRAYED hose without performing a

visual detailed inspection? The engineer was never present at the aircraft to physically look at the damaged HOSE. The sign off was "Maintenance reported a few damaged

threads on the subject Outer Braid". The EA accepts the noted condition as "permanent repair". This contradicts the findings of the write up! The FRAYED [hose] was broken

completely. Documentation was sent to the Engineer to look at. The EA was written as a

PERMANENT fix?

The maintenance manual states to replace damaged hose. If found FRAYED, bulged crossed threads or security of end fittings, and other signs of deterioration or damage. Are

we not following the MM procedures any longer? Are we so desperate to dispatch flights at the cost of people's lives? Are people being bullied into signing discrepancies at what cost?

Their jobs? People's lives?

We MUST follow the MM procedures and keep in mind that SAFETY of the passengers is at

stake when discrepancies are being signed off by supervisors and engineers that are not involved in the physical aspect of the airplane.

Synopsis

Maintenance Technician reported finding a slide pressure hose with frayed braiding, collapsed and contaminated, which was subsequently signed-off by a supervisor and

engineer as serviceable, contrary to the maintenance manual.

ACN: 1355607 (50 of 50)

Time / Day

Date : 201510


Place



Aircraft

Reference : X Make Model Name : Citation V/Ultra/Encore (C560)

Crew Size.Number Of Crew : 2

Flight Plan : IFR Flight Phase : Parked


Component

Aircraft Component : Aileron Trim System Manufacturer : Cessna



Person

Reference : 1

Location Of Person : Company Function.Maintenance : Inspector

Function.Maintenance : Technician Qualification.Maintenance : Inspection Authority


Events



Assessments


Narrative: 1

Technician working an aileron trim freezing in flight discrepancy called MCC (Maintenance

Control Center) and asked if SB27-3840 had been accomplished on the aircraft. Technician reported there is a warning note in the Aircraft Maintenance Manual (AMM) to not mix

different types of grease in the trim actuators. SB27-3840 changes the type of grease used in the trim actuators and cannot be mixed with other types of grease. The technician

needed to grease the aileron trim actuators to repair the discrepancy.

I searched [our maintenance software] for the status of SB27-3840 on this aircraft. No

status could be determined. A search of all aircraft affected by the Service Bulletin (SB) revealed only one aircraft had the SB signed off on it. All others neither showed complete

nor open. According to the aircraft maintenance records the SB had not been accomplished on this aircraft and I instructed the technician to us the pre-SB type of

grease. After I ended the phone call with the technician another maintenance controller commented he overheard my conversation with the technician about the grease and he

was pretty sure all the aircraft affected by SB27-3840 had the SB complied with. Another

search in the aircraft maintenance records [with our maintenance software] did not uncover any different information. I also tried to use [our older maintenance software]

which is a valuable resource for this type of situation, but discovered it had been locked down again and access was denied. [Our older maintenance software] would have easily

identified whether or not the SB had been accomplished prior to introduction of [current maintenance software]. There are many SBs and other critical information available in [our

older maintenance software] that cannot be identified in [our current maintenance software] because much of the [older maintenance software] aircraft information and

modifications or SB level status was not deemed worthy to transfer to [our current

maintenance software] which has quickly and routinely proved a mistake.

After researching SB27-3840 it was found that special markings were to be added to the aircraft near the trim actuators identifying the type of grease to be used when changed

during the SB. The technician was then called and notified to look for the special marks applied during compliance of SB. The technician found the marks indicating the SB was

complied with and he used the appropriate grease.

Having access to limited and incomplete aircraft information and SB compliance loaded

into [our current maintenance software] has been a source of frustration only [Maintenance] controllers experience.

Provide a system with easy access to all [Maintenance] controllers with complete SB,

Service Letters (SL) and other modifications status as [our older maintenance software] provided. [This software] is not a practical answer for accessing this information. It is not

an easy or intuitive program and [Maintenance] controllers do not know of its existence nor would they use it enough to become proficient with it. MOD level status of avionics

components is also a sore subject and leaves [Maintenance Control] guessing because that

is another identification not tracked in [our current maintenance software] yet [our current maintenance software] has the capabilities to record such information.

Synopsis

While working a trim freezing problem on a Cessna CE-560E, Maintenance could not determine if a Service Bulletin was accomplished on this aircraft to determine which type

of grease to use on the trim actuator.

ASRS Database Report Set - Maintenance Reports

Documents

Transcript of ASRS Database Report Set - Maintenance Reports