Mechanic

ASRS Database Report Set
Maintenance Reports
Report Set Description .........................................A sampling of reports from aircraft maintenance

personnel.
Update Number ....................................................28.0
Date of Update .....................................................January 29, 2016
Number of Records in Report Set ........................50
Number of New Records in Report Set ...............50
Type of Records in Report Set.............................For each update, new records received at ASRS will
displace a like number of the oldest records in the
Report Set, with the objective of providing the fifty
most recent relevant ASRS Database records. Records
within this Report Set have been screened to assure
their relevance to the topic.
National Aeronautics and
Space Administration
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: 1308695 (1 of 50)
Synopsis
Two Aircraft Maintenance Technicians (AMTs) report a right Main Landing Gear (MLG) on a
Fairchild (Swearingen) SA-227DC Merlin had collapsed as the aircraft was towed into the
hangar across an asphalt to concrete transition line. Three of the four bolts attaching one
of the two crescent shaped cams on the right MLG were found sheared.
ACN: 1307353 (2 of 50)
Synopsis
A Maintenance Technician reported a nose landing gear collapse when the tug was
unintentionally accelerated in reverse.
ACN: 1305894 (3 of 50)
Synopsis
A Maintenance Technician reported that following the deferral of an engine driven
hydraulic, the aircraft experienced an inflight engine shutdown due to the loss of engine
oil.
ACN: 1304978 (4 of 50)
Synopsis
A lead Maintenance Technician reported a process failure where propeller blades were
installed in the incorrect position during build-up, resulting in vibration when the assembly
was installed on an aircraft.
ACN: 1301789 (5 of 50)
Synopsis
A Line Aircraft Maintenance Technician reports that ramp personnel performing wing
walker duties do not stay with inbound aircraft at the arrival gate until ground power has
been established. A new fuel savings policy by their company, requires flight crews to
continue running the #1 Engine on B737NGs and A320 aircraft instead of using the APUs;
raising safety concerns for personnel and equipment behind the aircraft.
ACN: 1300292 (6 of 50)
Synopsis
A Maintenance Technician reported impacting a hangar during taxi when the nosewheel
steering system and brake system were disabled by the unreported activation of the
landing gear squat switch.
ACN: 1299377 (7 of 50)
Synopsis
A Maintenance Inspector reported the loss of an aileron hinge pin during a test flight
following adjustments for an out of trim condition.
ACN: 1299325 (8 of 50)
Synopsis
A Maintenance Technician described an engine high power run where the parking brake
became released, which resulted in the propeller contacting a piece of ground equipment.
ACN: 1299093 (9 of 50)
Synopsis
A Maintenance Technician reported that maintenance paperwork had been left in the work
area and caused a subsequent binding of the rudder cables.
ACN: 1297551 (10 of 50)
Synopsis
A Maintenance Controller describes the results of effective maintenance troubleshooting
after a Dassault-2000 flight crew reports their flap Circuit Breakers (CBs) had popped on
approach. Technicians found flap torque tubes had disconnected at the right wing trailing
edge between the Inboard (IB) and Outboard (OB) flaps.
ACN: 1295814 (11 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) with extensive DC-10 Engine Reverser
experience describes what he believes to be inaccurate Boeing Lamm schematics that
have contributed to engine pneumatic lines being attached at incorrect positions on Dual
Switcher Valves on GE-CF6-80 engines. The Switcher Valves are part of the FAAs Thrust
Reverser Safety Enhancement System A.D.
ACN: 1295357 (12 of 50)
Synopsis
Maintenance technicians reported that they were notified of a loose wing panel after a
passenger noticed it fluttering in flight. Several fasteners were found missing from the
panel.
ACN: 1294332 (13 of 50)
Synopsis
Several Maintenance Technicians reported difficult working conditions that resulted in
maintenance errors including the possible installation of the incorrect part number.
ACN: 1294072 (14 of 50)

Synopsis
A maintenance technician described the conditions that contributed to the installation of an
incorrect fan blade.
ACN: 1293413 (15 of 50)
Synopsis
Maintenance Technician reported that when electrical power was reapplied following the
routine replacement of a Metroliner engine fire extinguisher bottle, the bottle was
unexpectedly discharged. He revealed that wires had been incorrectly connected due to
mislabeling of the wires.
ACN: 1292485 (16 of 50)
Synopsis
Mechanics and Captain disagreed about the gauge display for the exit doors' pneumatic
charge. Different aircraft assigned.
ACN: 1291853 (17 of 50)
Synopsis
B767 Maintenance Technician was assigned the task of clearing a spoiler deferral, but was
unable to do so. The MEL was reinstated, but the spoiler handle was not tested and the
aircraft was dispatched with the spoiler restricted to 50% of normal.
ACN: 1291474 (18 of 50)
Synopsis
After their CRJ-200 aircraft had departed, two Aircraft Maintenance Technicians realized
they had installed a new carbon seal O-Ring at the wrong location on # 1 Engine
Integrated Drive Generator. # 1 Engine lost all oil in flight. Distraction, inadequate and
easy to misinterpret maintenance diagrams, work interruptions from Management, lack of
training and experience and a slow on-line Maintenance Manual program were noted as
contributors.
ACN: 1290978 (19 of 50)
Synopsis
Two Aircraft Maintenance Technicians reported recurring Right Main Landing Gear (MLG)
L/G Not UNLOCKED ECAM faults on an A320 aircraft. Aircraft ferried to a Line Maintenance
Station with limited resources. Right MLG Retract actuator replaced. No Flight Test
required. Aircraft departed but returned to field with ECAM Advisory message FLT L/G
DOWN. Found the L/G DOWN VMO (Maximum Operating Speed Limit)/MMO (Maximum
Mach Operating Speed) selection switch (22FP) on the 188VU panel inadvertently left in
the L/G down position. Reset switch to L/G 'Normal' position.
ACN: 1289759 (20 of 50)

Synopsis
An Aircraft Maintenance Technician reported finding a third Cessna CE-560XLS aircraft in a
month with Main Landing Gear Uplock Hook bushings worn during their Post Maintenance
Checklist inspections. Technician believed that since they have migrated from doing Phase
1-4 Inspections to performing Phase-A and Phase-B Inspections, the Uplock Detailed
Inspection Task has been overlooked.
ACN: 1289753 (21 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) working as an on-call Air Carrier Technical
Representative describes his excessively long, irregular work days, ever changing work
hours, lack of adequate support for re-scheduling hotels and fatigue from lack of sleep.
ACN: 1289750 (22 of 50)
Synopsis
An Aircraft Maintenance Technician recommended a specific tool be made or listed in the
Aircraft Maintenance Manual for technicians to use to avoid damage to CFM-56 Engine Fan
disks when removing the N1 Fan Blade Shim/Keeper weights. Inadvertent tooling damage
by Technician required unscheduled engine replacement on a B737-900 aircraft.
ACN: 1288221 (23 of 50)
Synopsis
A Maintenance Technician lost control of an aircraft following an expedited taxi across a
runway with approaching landing traffic.
ACN: 1287823 (24 of 50)
Synopsis
An Aircraft Maintenance Technician recommended his Air Carrier fix the malfunctions with
their IPAD/Digital communication software program that cleared a 'System-2 Regulator'
fault discrepancy instead of deferring the Logbook item.
ACN: 1282992 (25 of 50)
Synopsis
An Aircraft Maintenance Technician reported about a potential safety risk and improper
maintenance documentation practices after his Lead and Supervisor directed him to install
a faulted and unserviceable GFI Relay into a B747-400 aircraft that needed to be defueled
for maintenance. GFI was part of an airworthiness directive to disrupt electrical power to
fuel pumps in a fuel tank.
ACN: 1282664 (26 of 50)
Synopsis
A Maintenance Technician and Inspector describe the events that led up to the loss of
engine upper cowling from CRJ-200.
ACN: 1281886 (27 of 50)
Synopsis
A Maintenance Technician disagreed with a Lead Technician on the use of an electrical
conduit repair based upon the extent of the damage.
ACN: 1280088 (28 of 50)
Synopsis
A Maintenance Technician was advised that the part he replaced several months earlier
had been installed incorrectly. The fault was identified by the failure of the horizontal
stabilizer operational check during routine inspection.
ACN: 1279377 (29 of 50)
Synopsis
A Director of Maintenance and a pilot/mechanic reported that they had been advised of a
missed inspection signoff for an internal engine component, but that in discussion with a
FAA Principal Maintenance Inspector, the part was airworthy with the time remaining.
Later, the conclusion was questioned by another Principal Maintenance Inspector and was
under investigation.
ACN: 1278743 (30 of 50)
Synopsis
A Maintenance Inspector discovered that the Maintenance Supervisor was incorrect when
he reported that all of the engine change paperwork was completed when he requested
the final signoff.
ACN: 1278430 (31 of 50)
Synopsis
A distracted and overworked MD-82 Mechanic forgot to close the nose gear door following
a maintenance procedure the previous evening. After takeoff the next morning a severe
hydraulic system shudder during gear retraction caused the flight crew to lower the gear
and return to the departure airport.
ACN: 1278065 (32 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) reports he did not include any Aircraft
Maintenance Manual (AMM) reference in a logbook sign-off for replacement of a parking
brake light on a B737 that had illuminated intermittently at cruise with the parking brake
'off.'
ACN: 1277957 (33 of 50)
Synopsis
A Maintenance Technician neglected to fully remove power from the battery charger,
resulting in shorting of the contact terminal that required replacement.
ACN: 1277063 (34 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) reports finding the landing gear control cables in
the forward cargo pit ceiling wrapped around each other at approximately frame station
300 on a B767-300 aircraft. Pilots had made several previous write-ups for a stiff gear
handle with a "grinding noise and feel." A floor beam repair had recently been
accomplished that removed the cables. 'Clearance to Close' panels also an issue.
ACN: 1275197 (35 of 50)
Synopsis
An MD-80 had normal seats installed in two of the emergency exit seat rows. The seatback
tray tables could block the emergency exits.
ACN: 1274898 (36 of 50)
Synopsis
A Maintenance Controller reports about events surrounding an inappropriate deferral of an
APU for an EICAS L BLEED LEAK WARNING on a CRJ-900 aircraft at an outstation gate.
Controller also noted the significant lack of knowledge maintenance controllers have of the
pneumatic system, the untrained, ill equipped outstation mechanics, and the lack of
effective troubleshooting the cause of the EICAS warning.
ACN: 1274892 (37 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) was informed he had failed to completely review
the Maintenance Procedures previously accomplished under MEL 28-XX-XX, when a
Defueling Valve was found still safety wired closed after he had cleared the MEL. The
deferral had noted when selecting the Fuel Transfer switch on the Overhead panel to
'LOW', fuel would be supplied not only to the engine selected, but also to that side's wing
tank.
ACN: 1274216 (38 of 50)
Synopsis
A Quality Assurance (QA) Lead Technician reports about one of their AS-350 Eurocopter's
that was placed back in service with overdue Airframe and Powerplant 100-Hour and 700-
Hour inspection items not completed. His company operations had contracted with a news
gathering organization to provide an AS-350 on short notice. He notified his Director of
Maintenance (DOM) about the non-compliance, but the response was not very supportive
of his concerns.
ACN: 1274075 (39 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) reports not feeling comfortable with an order
from their Maintenance Supervisor to stop all testing and reassemble all the items they
had taken apart after an Altitude Pressure switch had failed and an EPR leak was
discovered on a B757-300 aircraft. The supervisor canceled the Job Cards and noted the
technicians involved were not operating equipment correctly. Replacement for a failed
Altitude Pressure switch was not available.
ACN: 1273178 (40 of 50)
Synopsis
A Line Aircraft Maintenance Technician (AMT) reports how a standard task card procedure
to check APU oils on their wide bodied aircraft within one hour of arrival by using the
EICAS page to determine if oil servicing was necessary, did not satisfy the requirement to
visually check the APU oil sight-glass for ETOPS flights. The B767-300 was originally
scheduled Out of Service (OTS), but later had an ETOPS flight scheduled.
ACN: 1272208 (41 of 50)
Synopsis
A Line Aircraft Maintenance Technician (AMT) describes his frustration and safety concerns
surrounding a manual engine start procedure on the ramp with limited personnel and
having to use hand signals without a standard set of guidelines for everyone to follow.
Headsets could not be connected to the MD-82 aircraft due to weather conditions.
ACN: 1272205 (42 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) was informed by a company pilot that one of
their Bell BHT-407 helicopters had a 'FADEC Degraded' light illuminate in flight. The
intermittent fault would occur every ten to twelve hours and had been an on-going
problem for months that could not be duplicated in the hangar.
ACN: 1272196 (43 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) recommends an additional reference be added
to Airworthiness Directive (AD) 2012-11-09 to include Illustrated Parts Catalog (IPC) 35-
21-01-40b, (item C). The IPC would provide a better understanding of the Passenger O2
mask box release cable routing. Misunderstanding of Step 2 of the AD resulted in an
incorrect installation of the release cable and O2 masks on a B777-200 aircraft.
ACN: 1271618 (44 of 50)

Synopsis
An Aircraft Maintenance Technician (AMT) reports finding a B737 weather radar unit 'On'
and running in the hangar during aircraft maintenance. Technician noted the need for
documentation to protect workers from the health hazards of radar operations should also
include pulling the Radar Circuit Breaker (C/B) before maintenance is performed.
ACN: 1270807 (45 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) reports about his Maintenance Manager who
continually attempts to cover up discrepancies with the aircraft they have at their Flight
Facility. Technician also includes examples of the same Manager applying pressure to
perform maintenance or modifications to their aircraft, not in compliance with their
Practices and Procedures Manuals.
ACN: 1270752 (46 of 50)
Synopsis
An Aircraft Maintenance Inspector reports using LED Ultraviolet type lights for Fluorescent
Penetrant Inspection (FPI) of Rolls Royce Engine parts for more than two years, believing
an Engineering Variance had been issued to allow the use of the LED lights.
ACN: 1270457 (47 of 50)
Synopsis
A Line Aircraft Maintenance Technician (AMT) reports about an unrecognized critical safety
issue that exists for pilots to lose control of B757/B767 aircraft on approach, if the pilot
seat shifts unexpectedly due to broken Seat Track Lock Control assemblies. Technician
suspects the routine seat inspection task card is not sufficient to maintain adequate
serviceability of crew seats.
ACN: 1270323 (48 of 50)
Synopsis
Two Maintenance Controllers, an Aircraft Maintenance Technician (AMT) and a Captain
describe their involvement with a reported # 2 Engine Fuel Spar Valve Overhead Blue light
fault that was miscommunicated and deferred as an Engine Valve Blue fault light on a
B737-800 aircraft. A downline Maintenance Station noted that the original discrepancy and
the resolution did not match. Spar valve was replaced and Engine Valve MEL cleared.
ACN: 1270315 (49 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) reports placing a 2" x 4" board against the outer
lip of the Left Main Landing Gear (MLG) door after completing a Center Axle alignment on
a B777 aircraft. MLG door was closed later, but the 2X4 fell out of the wheel well after
takeoff also told from the perspective of the Captain of the flight. Distractions, workload
and limited staffing were contributors.
ACN: 1269736 (50 of 50)
Synopsis
An Aircraft Maintenance Technician (AMT) reports about the efforts made to locate a 1/4"
inch drive, 7/16" inch shallow socket that was unaccounted for after a Forward (FWD) Fuel
Cell replacement on a Bell BHT-407 helicopter. Inspections of critical areas that would
effect safety of flight were accomplished; socket not found. Fuel tanks were not drained.
Training Flight crew accepted aircraft for service.
Report Narratives
ACN: 1308695 (1 of 50)
Time / Day
Date : 201511
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Light : Daylight
Aircraft
Reference : X
Aircraft Operator : Air Taxi
Make Model Name : SA-227 AC Metro III
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 135
Flight Plan : IFR
Mission : Passenger
Flight Phase : Parked
Maintenance Status.Released For Service : N
Maintenance Status.Maintenance Type : Unscheduled Maintenance
Maintenance Status.Maintenance Items Involved : Inspection
Maintenance Status.Maintenance Items Involved : Installation
Maintenance Status.Maintenance Items Involved : Repair
Maintenance Status.Maintenance Items Involved : Testing
Component : 1
Aircraft Component : Main Gear
Manufacturer : Fairchild/Swearingen
Aircraft Reference : X
Problem : Failed
Component : 2
Aircraft Component : Gear Extend/Retract Mechanism
Manufacturer : Fairchild/Swearingen
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person : Hangar / Base
Reporter Organization : Air Taxi
Function.Maintenance : Lead Technician
Qualification.Maintenance : Powerplant
Qualification.Maintenance : Airframe
ASRS Report Number.Accession Number : 1308695
Human Factors : Confusion
Human Factors : Time Pressure
Analyst Callback : Completed
Person : 2
Reference : 2
Location Of Person : Gate / Ramp / Line
Function.Maintenance : Technician
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
Detector.Person : Maintenance
Were Passengers Involved In Event : N
When Detected : Taxi
Result.General : Maintenance Action
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
Was brought out to tow aircraft to hangar for hangar installation. Hooked up tow bar after
shutdown, hooked tug to towbar, got okay to tow, wing walkers thumbs up, towing was
successful until aft right Main Landing Gear (MLG) tires hit a small one inch lip at asphalt
to concrete change point, right main gear folded at this point and right side of aircraft hit
the ground asphalt/concrete.
It was discovered that the cause of the problem was shearing of the main gear cam bolts.
My only recommendations are a fleet campaign and or, if the problem proves to be
affiliated with specific design of the aircraft possibly a Service Bulletin (SB) or
Airworthiness Directive (AD) that makes the change of the bolts at regular intervals
mandatory. Towing after ferry flight.
Callback: 1
Reporter stated his air taxi has already started a fleet campaign to check the four bolts
and self-locking nuts that attach two crescent moon shaped cams on the forward drag
brace of each main gear strut. Two hydraulic actuators one for (up) and one for the
(down) movement of each Main Landing Gear (MLG) have a bearing that ride in the
crescent section and rotate the MLG. The Main Landing Gears do not use a traditional
overcenter locking brace.
Reporter stated the Fairchild (Swearingen) Merlin had just arrived after a ferry flight for a
landing gear door system problem. The prop, nose cone and planetary gears were
damaged after the MLG collapsed. Three of the four cam attach bolts at one of the two
cams for the right gear had completely sheared and the fourth was half sheared. He
suspects that was an isolated incident, but is also aware the cam bolts are not normally
removed and inspected for condition during Maintenance checks. He believes the Main
Landing Gears had been changed recently. Aircraft should be jacked up to replace the
bolts. He recommends at least a torque check of the cam bolts and self-locking nuts which
may indicate if some have already sheared.
Narrative: 2
I was walking in, the right wing of the aircraft, as it was being pushed back into the
hangar, the right Main Landing Gear (MLG) collapsed and the right wing hit the ground in
front of me.
[Recommendations]: Nothing comes to mind since any defects were unknown at time of
occurrence [during] aircraft push back into hangar.
Synopsis
Two Aircraft Maintenance Technicians (AMTs) report a right Main Landing Gear (MLG) on a
Fairchild (Swearingen) SA-227DC Merlin had collapsed as the aircraft was towed into the
hangar across an asphalt to concrete transition line. Three of the four bolts attaching one
of the two crescent shaped cams on the right MLG were found sheared.
ACN: 1307353 (2 of 50)
Time / Day
Date : 201510
Place
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : Medium Large Transport, Low Wing, 2 Turbojet Eng
Mission : Passenger
Maintenance Status.Maintenance Deferred : N
Component
Aircraft Component : Nose Gear
Problem : Improperly Operated
Person
Reference : 1
Reporter Organization : Air Carrier
Experience.Maintenance.Technician : 17.5
Human Factors : Situational Awareness
Human Factors : Distraction
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
When Detected.Other
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was pushing aircraft to park at hangar. Once chocked was going to pull the push tractor
back and in to set it up for a crewmate to pull the pin out. As I thought I had my foot on
the brake had it on the accelerator, the tractor lunged backwards and pulled the front nose
strut out and the aircraft collapsed. Nobody was injured and all were safe.
Synopsis
A Maintenance Technician reported a nose landing gear collapse when the tug was
unintentionally accelerated in reverse.
ACN: 1305894 (3 of 50)
Time / Day
Date : 201509
Place
Aircraft
Reference : X
Make Model Name : Regional Jet 700 ER/LR (CRJ700)
Flight Plan : IFR
Mission : Passenger
Component : 1
Aircraft Component : Powerplant Lubrication System
Problem : Failed
Component : 2
Aircraft Component : Hydraulic System Pump
Person
Reference : 1
Human Factors : Troubleshooting
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Procedural : Maintenance
Detector.Person : Flight Crew
Result.Flight Crew : Diverted
Result.Flight Crew : Inflight Shutdown
Assessments
Primary Problem : Ambiguous
Narrative: 1
We were called out to aircraft for a #1 hydraulic system quantity low. Serviced the #1
system in accordance with Aircraft Maintenance Manual (AMM). We noticed Skydrol leaking
out of the #1 engine drain port. Opened the #1 engine cowl and found the #1 Engine
Driven Pump (EDP) to be leaking when the engine was motored over. Proceeded to
remove and perform deactivation procedures of the #1 EDP in accordance with AMM. After
completion of the deactivation ran the #1 engine for leaks and no leaks were noted.
Aircraft was then dispatched with a #1 EDP deferred.
Aircraft was dispatched with a #1 EDP [deactivated] and was diverted due to #1 engine
loss of engine oil resulting in engine shut down.
It would be better if the AMM would be more detailed in the leak check procedure.
Synopsis
A Maintenance Technician reported that following the deferral of an engine driven
hydraulic, the aircraft experienced an inflight engine shutdown due to the loss of engine
oil.
ACN: 1304978 (4 of 50)
Time / Day
Date : 201510
Place
Aircraft
Reference : X
Make Model Name : SF 340A
Mission : Passenger
Component : 1
Aircraft Component : Propeller Assembly
Component : 2
Aircraft Component : Propeller Blade
Person
Reference : 1
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Maintenance
Events
Assessments
Narrative: 1
I was the lead mechanic for a propeller build-up during which #2 and #4 blades were
swapped. When the prop was finally put on a plane a month later, the airplane
experienced excessive vibration. This is when the prop was inspected and found that
blades were installed in the wrong locations. I think the blades were installed improperly
because too many people were involved in the build-up. Blades #1 and #3 were installed
first so I think we just got confused as to which side #2 went on. Inevitably after installing
#2 incorrectly, then #4 would also be incorrect. I think we also failed to double-check our
work like we did when installing #1 blade.
Synopsis
A lead Maintenance Technician reported a process failure where propeller blades were
installed in the incorrect position during build-up, resulting in vibration when the assembly
was installed on an aircraft.
ACN: 1301789 (5 of 50)
Time / Day
Date : 201510
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : B737 Next Generation Undifferentiated
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Component
Aircraft Component : Engine Exhaust System
Person
Reference : 1
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Ground Personnel
Events
Anomaly.Ground Event / Encounter : Other / Unknown
When Detected : Aircraft In Service At Gate
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Staffing
Contributing Factors / Situations : Company Policy
Primary Problem : Company Policy
Narrative: 1
We have been having personnel safety issues regarding jet blast from inbound flights
getting parked at the terminal gates. The Wing Walker of an inbound flight leaves his or
her post after the aircraft is inside the gate envelope, rendering the Wing Walker duty
void. After an inbound flight is inside the gate envelope the Wing Walker follows the
aircraft for other duties, leaving the traffic zone [exhaust] area behind the aircraft
unattended. Usually, with a lengthy void of unattended Wing Walker duty, the traffic
unaware, starts to cross behind the running engine (other waiting traffic has already
turned around to find other alternative route). This has caused repeated jet blast
conditions, it is a matter of time when a serious injury will occur. Other Aircraft
Maintenance Technician (AMTs) or Aircraft Electronics Technician (AETs) have voiced
concerns to the matter with no avail. The main concern of this report is to get Wing
Walkers to stay at their post till engines shut down.
I want to bring up a safety issue addressing Ramp Tower, Idle Engine Run Safety on the
Terminal Gates. I have filed a report and have discussed the issue with some management
personnel from my department (Aircraft Maintenance) and some Ramp safety personnel
over the last few months, but I thought it might be a good idea to include ATC, Local Air
Carrier Ramp Tower Management also, concerning this issue.
[Our] Air Carrier's new Fuel Savings Policy: (Flight crews on incoming flights for NG737,
A319/320 aircraft are required to pull onto gate [with] APU OFF and continue to Run #1
Engine until Ground Power is connected and verified online before shutting down # 1
Engine.) This practice has been in force for a few months now and there are many safety
concerns and problems that have arisen due to the # 1 engines extended Run times on
the Gate. What is supposed to take place in about 30-seconds (Hook up GRD PWR/ Shut
down # 1) has been observed by many of us to take up to two minutes or more as
problems arise hooking up Ground Power. During this extended Engine Run Time, I and
others have reported to Management on more than one occasion, Safety Hazards related
to the extended engine run time.
50% of the time there is no safety Wing walkers with safety wands giving the warning
signal of a running engine to Ground personnel. Several incidents of Ground personnel
driving behind near, or on foot, near the running engine. On windy days I have personally
seen paper FOD blown near the inlet of the running engine and getting ingested causing
me to later inspect the inlet and remove debris in # 1 Engine. Myself and others I have
talked to (including Flight crews) being under the duress of concern that it's just a matter
of time before someone or something large gets ingested into # 1 Engine. Little if any
significant fuel savings to justify the risks involved of the extended # 1 Engine run time.
As far as I know, there is still no written Safety Policy in effect for Ground personnel to
support the new Fuel Savings Policy. I had a Ramp person tell me that this new policy
does not require in writing, [that] Wing Walkers stay behind the aircraft's Left side with
safety wands to warn other Ground personnel of the Running Engine? So, some Ramp
personnel refuse to do it. So, after they wing walk and the brakes are set, they just drop
their wands and walk away with the # 1 Engine still Running. Pounds per Hour (PPH) the
APU burns less fuel than a running engine? When Maintenance performs an engine run on
the gate for maintenance reasons, we have to get permission from Ramp Tower on radios
and we are required to have safety Ground personnel with wands in place to warn Ground
personnel of the running engine. The Jet ways are being brought up to the aircraft while
the engine is still running on many occasions.
Synopsis
A Line Aircraft Maintenance Technician reports that ramp personnel performing wing
walker duties do not stay with inbound aircraft at the arrival gate until ground power has
been established. A new fuel savings policy by their company, requires flight crews to
continue running the #1 Engine on B737NGs and A320 aircraft instead of using the APUs;
raising safety concerns for personnel and equipment behind the aircraft.
ACN: 1300292 (6 of 50)
Time / Day
Date : 201510
Place
Aircraft
Reference : X
Make Model Name : Citation X (C750)
Mission.Other
Flight Phase : Taxi
Component : 1
Aircraft Component : Squat Switch
Component : 2
Aircraft Component : Normal Brake System
Component : 3
Aircraft Component : Parking Brake
Person
Reference : 1
Location In Aircraft : Flight Deck
Events
Anomaly.Ground Event / Encounter : Object
Anomaly.Inflight Event / Encounter : Object
Result.Flight Crew : Took Evasive Action
Assessments
Narrative: 1
The aircraft was not on [the FBO] ramp but we saw it on the customs ramp. We got to the
aircraft and started a walk around. I plugged in the batteries and pulled the main chock.
The other technician hooked up the torque links. I got in the aircraft in the pilot seat and
looked over the CB panel and the various switches in the cockpit. I turned the batteries
on. I turned the aux hydraulic switch on the buildup press and set the brakes. With brakes
set the nose chock was pulled. I started the APU and got the generator on line. I turned on
the inverters and turned on the AHRS [attitude and heading reference system] and power
supply. With avionics up I started the right hand engine. With the engine running and
amps at a good level, I started the left engine. I checked the oil pressures and hydraulic
pressures. I called ground [control] for clearance to taxi to [FBO ramp]. With clearance I
pushed the brake off and started rolling. I went to turn and had no nose wheel steering. I
applied the brakes and had no brakes. I pulled the parking brake handle and had no
results. I was closing in on the hangar in front of me and shut down the engines to avoid
damage to the engines. I impacted the hangar right after that. I shut down the APU and
shut down the power. I then got out of the aircraft and unplugged the batteries. After a bit
of time talking to the [airport personnel] I then thought of squat switches as a possible
problem and found the squat switches were manually placed in air mode.
Suggestions
1) Documentation of tooling installed on aircraft
2) Flags on all maintenance lockout/pins etc
3) Inspection Buy Back of ground lock devices being removed
Synopsis
A Maintenance Technician reported impacting a hangar during taxi when the nosewheel
steering system and brake system were disabled by the unreported activation of the
landing gear squat switch.
ACN: 1299377 (7 of 50)
Time / Day
Date : 201510
Aircraft
Reference : X
Aircraft Operator : Personal
Make Model Name : Cessna 180 Skywagon
Mission : Test Flight
Flight Phase : Cruise
Maintenance Status.Records Complete : N
Component
Aircraft Component : Aileron
Person
Reference : 1
Reporter Organization : Personal
Function.Maintenance : Inspector
Qualification.Maintenance : Inspection Authority
Experience.Maintenance.Inspector : 20
Events
When Detected : In-flight
Assessments
Primary Problem : Procedure
Narrative: 1
Pilot said aircraft was flying out of trim. Maintenance adjusted and flew aircraft after
preflight. Trim was adjusted and second flight made. On second flight left hand aileron
moved back from outboard hinge. Aircraft was flown back to airport. Found left outboard
hinge pin missing and aileron bent.
Synopsis
A Maintenance Inspector reported the loss of an aileron hinge pin during a test flight
following adjustments for an out of trim condition.
ACN: 1299325 (8 of 50)
Time / Day
Date : 201510
Place
Aircraft
Reference : X
Make Model Name : Medium Transport, High Wing, 2 Turboprop Eng
Mission : Passenger
Component : 1
Aircraft Component : Propeller
Component : 2
Person
Reference : 1
Events
Anomaly.Ground Event / Encounter : Object
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
When Detected : Routine Inspection
Result.Flight Crew : Regained Aircraft Control
Assessments
Narrative: 1
During a high power performance run, at approximately 96% torque, the parking brake
handle released and the plane lurched forward, jumping the chocks. The left engine struck
the GPU and damaged the #1 propeller. The aircraft movement was stopped by applying
the toe brakes, retarding the throttles and reapplying parking brake. [In the future] chock
all three gear, remove GPU from run area.
Synopsis
A Maintenance Technician described an engine high power run where the parking brake
became released, which resulted in the propeller contacting a piece of ground equipment.
ACN: 1299093 (9 of 50)
Time / Day
Date : 201509
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Maintenance Status.Maintenance Deferred : Y
Maintenance Status.Records Complete : Y
Maintenance Status.Released For Service : Y
Component
Aircraft Component : Rudder Control System
Person
Reference : 1
Reporter Organization : Contracted Service
Experience.Maintenance.Technician : 7
Events
Result.Flight Crew : Overcame Equipment Problem
Assessments
Narrative: 1
I was called out to defer the L/H wing anti-ice valve per MEL on a CRJ-700. The work was
completed but I apparently left the MEL manual paperwork in the area of the valve. Later
the flight crew made a maintenance discrepancy that they felt binding in the rudder. The
paperwork that was left in the valve area had worked its way to the flight control cables
and was rubbing against the rudder cables.
To prevent a recurrence I will double check that all paperwork has removed after the work
has been complete.
Synopsis
A Maintenance Technician reported that maintenance paperwork had been left in the work
area and caused a subsequent binding of the rudder cables.
ACN: 1297551 (10 of 50)
Time / Day
Date : 201509
Place
Environment
Light : Daylight
Aircraft
Reference : X
Aircraft Operator : Fractional
Make Model Name : Falcon 2000
Component : 1
Aircraft Component : Flap Control (Trailing & Leading Edge)
Manufacturer : Dassault
Component : 2
Aircraft Component : Flap/Slat Control System
Manufacturer : Dassault
Person
Reference : 1
Reporter Organization : Fractional
Events
Result.Flight Crew : Overcame Equipment Problem
Assessments
Narrative: 1
On approach, the crew noted that the flap Circuit Breakers (CBs) were popped; landing
was uneventful. After a day of waiting on parts and changing Printed Circuit Boards
(PCBs), (normal action for such a squawk). Technicians inspected the flaps and noted the
following:
Continued investigation into flap issue on [the] Aircraft, a Falcon DA-2000. After removing
right wing Inboard (IB)/ Outboard (OB) flap junction fairings, found OB flap impacting flap
interconnect control rod and trailing edge of the OB flap below the IB flap. Upon
comparison to left wing found IB flap travel greater than OB flap. Removed trailing edge
panel on right wing, between IB and OB flap and found torque tubes disconnected. Only
speculation, but when the aircraft recognized a [difference], it stopped the flap movement;
but because OB flap was disconnected, it continued to spool down for some reason where
it impacted IB flap interconnect rod. Bolt in flap torque tube appears to be fully installed in
clamp with locking washer properly installed. I suspect when torque tubes were last
removed the bolt was not engaged in the groove on the spline upon reinstallation
therefore allowing the torque tubes to migrate apart over time. [Recommend] [clearance]
(okay to close) and final Required Inspection Items (RII) inspections should be followed.
Synopsis
A Maintenance Controller describes the results of effective maintenance troubleshooting
after a Dassault-2000 flight crew reports their flap Circuit Breakers (CBs) had popped on
approach. Technicians found flap torque tubes had disconnected at the right wing trailing
edge between the Inboard (IB) and Outboard (OB) flaps.
ACN: 1295814 (11 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : DC-10 Undifferentiated or Other Model
Maintenance Status.Maintenance Type : Scheduled Maintenance
Maintenance Status.Maintenance Items Involved : Work Cards
Component : 1
Aircraft Component : Pneumatic Valve/Bleed Valve
Manufacturer : Middle River Aircraft Systems
Component : 2
Aircraft Component : Other Documentation
Manufacturer : Boeing
Person
Reference : 1
Qualification.Maintenance : Avionics
Experience.Maintenance.Avionics : 15
Human Factors : Training / Qualification
Communication Breakdown.Party2 : Other
Events
Assessments
Contributing Factors / Situations : Manuals
Narrative: 1
NOTE: This Maintenance report applies to all company DC-10 Aircraft, not just Aircraft X.
The Pressure Regulating Shutoff Valve (PRSOV) and Overpressure Shutoff Valve (OPSOV)
connections to all TRAS Lock Engine Duel Switcher valves are not connected properly. It
has been verified via company Engineering that the PRSOV valve is actually connected to
the Dual Switcher Valve OPSOV connection and the OPSOV valve is actually connected to
the Dual Switcher Valve PRSOV connection. The connections are backwards. This is
causing some Thrust Reversers to stow during Auto Re-Stow Testing in Maintenance. If the
lines were properly connected, the Thrust Reverser would not be able to stow during
testing.
Flight Safety - It has always been my understanding that the OPSOV is solenoid controlled
air to the Dual Switcher Valve. A company Engineer recently pointed out that engine air is
actually at the Dual Switcher Valve anytime the engine is running. He showed me the
[McDonnell-Douglas] LAMM schematic which shows the air flow to the Dual Switcher Valve
with no solenoid control. The PRSOV valve could be open in flight as it is on the ground
during the Auto Re-Stow test as a result of the lines being connected backwards.
[Recommend] to properly connect the lines to the Dual Switcher Valve. Verify if the
OPSOV air is still solenoid controlled air. If not, then we must connect the lines to the Dual
Switcher Vavle properly. If the OPSOV is solenoid operated, then inform Engineering and
change the LAMM [schematic] to reflect this.
Callback: 1
Reporter stated he has been working avionics and thrust reversers for over twenty-five
years. The Thrust Reverser Actuation System (TRAS) and mechanical Locks are part of an
FAA A.D. that also requires installation and testing of a Dual Switcher Valve component on
each GE CF6-80 series engines with connections for the Pressure Regulating Shutoff Valve
(PRSOV) and Overpressure Shutoff Valve (OPSOV) rigid pneumatic lines. The whole intent
of the AD is to reduce the potential for reverser deployment in flight. Three requirements
must be met to allow the PSROV air to be available for reverser movement.
Reporter stated he believes the engine pneumatic lines to the Dual Switcher Valve were
misrouted during the initial Switcher valve installation approximately several years ago.
The pneumatic flow line from the OPSOV that should go to the OPSOV on the Dual
Switcher Valve actually goes to the PSROV connection on the Switcher Valve which should
have air flowing out, not into the Switcher Valve. As a result, the pneumatic air line that
should have been connected to the Switcher Valve for 'air flow to' the PRSOV was
connected to the OPSOV port on the Switcher Valve. Pneumatic air pressure was/ is on the
wrong side of the Switcher Valve. The Dual Switcher Valves have four lines. Three lines
are input and one line for output. The Boeing LAMM schematic also shows air pressure at
all times, but that is not correct, because there is a solenoid that actually interfaces and
does not allow the PSROV to open unless the same three conditions are satisfied.
Reporter stated he would like to see two issues addressed. 1) switch the pneumatic lines
at the Dual Switcher Valve to operate correctly. 2) Revise the Boeing LAMM schematic for
the two pneumatic line connections to the Switcher Valve to prevent continued incorrect
stowing of reversers during Auto-Re-Stow Testing of the Switcher Valve and reversers.
Synopsis
An Aircraft Maintenance Technician (AMT) with extensive DC-10 Engine Reverser
experience describes what he believes to be inaccurate Boeing Lamm schematics that
have contributed to engine pneumatic lines being attached at incorrect positions on Dual
Switcher Valves on GE-CF6-80 engines. The Switcher Valves are part of the FAAs Thrust
Reverser Safety Enhancement System A.D.
ACN: 1295357 (12 of 50)
Time / Day
Date : 201509
Place
Aircraft
Reference : X
Make Model Name : B767-200
Mission : Passenger
Maintenance Status.Required / Correct Doc On Board : Y
Component
Aircraft Component : Wing Access Panel
Person : 1
Reference : 1
Person : 2
Reference : 2
Events
Detector.Person : Passenger
Were Passengers Involved In Event : Y
Assessments
Narrative: 1
After arrival was informed by flight attendant that a passenger reported that an access
panel on top of the left wing appeared to only have one fastener holding it on and that it
was fluttering in flight. Upon further investigation it was found that 15 out of 17 screws
were missing. Installed fasteners in panel and made a log entry.
Narrative: 2
This was the panel that is over the landing gear retract actuator 551CT. Panel was
secured.
Synopsis
Maintenance technicians reported that they were notified of a loose wing panel after a
passenger noticed it fluttering in flight. Several fasteners were found missing from the
panel.
ACN: 1294332 (13 of 50)
Time / Day
Date : 201506
Environment
Work Environment Factor : Temperature - Extreme
Aircraft
Reference : X
Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
Operating Under FAR Part.Other
Mission : Ambulance
Component
Aircraft Component : Power Drive System
Person : 1
Reference : 1
Location Of Person : Repair Facility
Human Factors : Fatigue
Human Factors : Workload
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Weather
Narrative: 1
I work in a 145 Repair station as a hangar mechanic, and I was asked to go to assist in a
swashplate change on an AS350B3 that was stuck on the hospital landing pad due to a
swashplate shim protruding from the center of the swashplate. The repair took 11 days.
We had been working very long hours (10-14hrs daily) in very hot weather all outside on
top of the Hospital pad where the helo was stranded. During the swashplate change after
disassembly of the main gear box we noticed that the bolt holes had corrosion build up in
them and the ring gear had also been corroding due to bad sealant on the bolt heads, so
we ended up removing the entire assembly and changed out the epicyclic and housing at
the same time. During the reassembly of the housing and epicyclic, (we had been working
for 14 hours that day) we decided to call it and to get some rest. I left to go to my hotel
and came back in the morning to find that the epicyclic had already been installed into the
housing, however, during my RII of the installation I noticed that the gearbox and
epicyclic had been coated with Turco instead of mineral oil which is what is called out for. I
notified the lead and he said they had installed it after I left. So they came up to the pad
to confirm and ended up flushing the system out before we installed the rest of the mast
and components. The lead mechanic was instructing and helping to assemble the mast and
swashplate assembly (the Maintenance Manual (MM) reference was printed out and we
were going step by step). We had to take breaks often due to how hot it would get on top
of the hospital but the job got finished.
[Several months later] the helicopter was trucked in for a tail rotor strike. During a brief
incoming inspection and cleaning another mechanic noticed that the dust cover and or
boot that covers the top of the swashplate was missing.
During our maintenance ops, there were many people constantly calling to figure out when
we would be done which caused many distractions, so less or no phone calls during
maintenance ops on an Aircraft on Ground (AOG) aircraft would be immensely helpful. If
the aircraft is stuck on the helipad or in an area where it cannot be moved to a hangar,
putting up a temp shelter (roof tent) or something like that would help immensely with
less fatigue and possible heat stroke, which in turn leads to more mistakes and less work
time due to the time spent trying to cool down and regulate body temp and sunburn. No
pilot interaction during these maintenance ops would also help a lot, it makes our jobs as
mechanics a lot harder when we not only have supervisors and their bosses phoning us all
the time to then have the pilot ask how much longer.
Narrative: 2
This aircraft was removed from service and placed under unscheduled maintenance for
removable shims extruding from the swashplate on top of the hospital helipad. A
[contract] was submitted for outside help as the maintenance crew on staff had not
performed this job to a level of comfort. Maintenance support arrived for assistance. Upon
removal of the mast assembly, it was noted that the epicyclic gearbox and sun gear
assembly were corroded beyond limits, further increasing the workload on the [roof] of the
hospital in the middle of summer, requiring a full transmission replacement. Initially, we
were told that removing the aircraft from the hospital by crane was not the best option at
the time, as we were only to be performing a couple days' worth of work, but when the
corrosion was found, it would have taken the same amount of time to reinstall everything
needed to crane the aircraft as to put it back together to return to service. The removal,
disassembly, reassembly, and return to service took us 10 days of all mechanics working
over 10 hours per day. During this time I worked on and off with the mechanics
performing the maintenance, as I am the lead mechanic for the program and had other
priorities. During this 10 day event I called a safety stand down day on day 7 as the
maintenance crew was showing signs of heavy fatigue, both mentally and physically. The
installation, ground runs, and check flights were completed and the aircraft was returned
to revenue service. While I was not the primary mechanic on this job, I feel it necessary to
submit this as I did help and did not notice the issue.
[Over 2 months later] this aircraft was involved in a tail rotor strike at a scene call. This
aircraft was loaded on a truck and shipped to a repair station for maintenance required for
the tail rotor strike inspection. During acceptance inspection, it was noted that the
swashplate appeared to be missing the dust cover on top of the swashplate. I was notified
by my supervisor, and began researching this issue. After consulting the removal and
installation part numbers, it became apparent that the installed part number was not
effective for this aircraft. After consulting the maintenance staff involved, and looking at
the Illustrated Parts Catalog (IPC) for this install, we could not find the correct swashplate
in the IPC, and the only part number shown was the one that was installed. The repair
station has the aircraft at this time, and will make the repairs as necessary. This event
was an eye opener to all of us as we look back to all of the long hours that were put in to
get this aircraft back in service, and that sometimes we need to take a step back and look
at ourselves before we look at the work ahead of us.
In my opinion, there were multiple factors that lead to this incident. Maintenance staff was
pressured, both personally and by the customer, to provide an expedited service that
could not be met. Maintenance pressures were also felt from the heat during this time of
the year, on top of an aluminum helipad, with no shade available at the aircraft. The
airframe IPC played a large role in the incorrect ordering of parts, as the IPC is somewhat
vague when it comes to ordering parts for aircraft with different modifications installed
(i.e. dual hydraulics in this case). I believe this incident could have been avoided if the
aircraft had been removed from the hospital from the very beginning, removing the
pressures from the hospital on a direct level.
Narrative: 3
I was notified that an aircraft had been sent by ground transport to the Repair Station due
to a Tail Rotor strike. I was made aware that during the receiving inspection into the repair
station that it was discovered that the Main Rotor Swashplate assembly was missing the
top dust cover (boot). Later during this day it was also brought to my attention by the
Lead Mechanic that after discussing this situation with Mechanic that was currently on duty
that the Swashplate that is currently installed may be the incorrect assembly.
Due to a previous recent event, the swashplate had been replaced. The replacement was
due to a peel shim that was found during a preflight check that was partially ejected from
the top of the uniball. The work for this replacement was [accomplished several months
ago]. While attempting to order the replacement swashplate I was unable to find the
replacement part number for this assembly in the online AS350B3 Illustrated Parts
Catalog. I notified the lead mechanic to inform him that I was unable to find this part
number. After some discussion we both agreed that the Airbus Helicopter Technical
Representative should be called for support.
I immediately called the Tech. Rep. and explained my situation and that this was to be
installed on an AS350B3 with Dual Hydraulics. I was told that I would not find that part
number in the AS350B3 IPC and that I would need the part numbers found on the
Component Cards for the Rotating and Non-rotating Swashplates (sub-assembly part
numbers) and that he would send me a sheet that would give a breakdown of these part
numbers that would provide the Swashplate Assembly part number (Next Higher
Assembly) that was needed. This Swashplate was ordered and properly received into the
base. Before the work for the replacement of this Swashplate began, I voiced concerns
with the Lead Mechanic that although I have performed this maintenance tasking before
for a swashplate replacement on an AS350B3, it had been maybe as long as 6 years since
the last time I had done this and I had not done this task on an AS350B3 with Dual
Hydraulics. This coupled with the fact that this was a brand new base and that this
maintenance was to be performed on the roof of the hospital with temperatures that were
to be in the high 90's were also concerns that I voiced. The lead mechanic agreed that we
would need additional support. He made arrangements to have a mechanic experienced at
this procedure sent from another Repair Station and requested that I was to perform this
as OJT that was to be documented in the OJT book provided to the field mechanics.
Another experienced Mechanic was also sent for additional maintenance support.
Although another mechanic signed off this installation, the three mechanics, myself
included, involved in this installation shared equally the responsibility of this installation. I
provided the RII and at that time I should have reviewed the installation procedure again
with the two mechanics. I believe that each one of us were under the impression (although
now knowing it to be wrong) that because the assembly that came off did not require the
boot that this was still the case with new assembly that went on.
I have reviewed the procedure in the AS350B3 Aircraft Maintenance Manual (AMM) for the
installation of the swashplate onto the Mast Assembly again and it does not distinguish
between the different assembly types with either the required dust boot or a rain guard as
is found on the AS350B3's with dual hydraulics. The procedure does call out for the
installation of the boot and in retrospect I feel now that I should have questioned our
installation at this time. There is also nothing that I could find on the hard cards that
distinguish the installation of the rain guard as opposed to the lip ring used for the
installation of the dust boot. I feel the process for determining the part number for the
Swashplate assembly is convoluted and not in good practice. I should have questioned this
process at the time that I did not find the part number in the IPC.
I believe there were more challenges with this swashplate change and eventually the Main
Gearbox than normal in a field environment. This was a brand new base that was not
completely equipped yet to handle this type of heavy maintenance. The fact the work that
was to be completed on the roof of the hospital where the OAT was 95 to 100 degrees F
each day and that we were on a metal helipad was extremely challenging. The teardown of
the main gear box and Mast Assembly was completed in a small room on the roof of the
hospital just outside the elevator with no air conditioning or circulation of air. We worked
10 to 14 hours each day in order to reach our goals. Word was getting passed on to us
about some of the outside pressures to have the aircraft back in service and that this was
a new base and a new contract that was taken over and that this issues did not exist with
them.
Synopsis
Several Maintenance Technicians reported difficult working conditions that resulted in
maintenance errors including the possible installation of the incorrect part number.
ACN: 1294072 (14 of 50)
Time / Day
Date : 201509
Place
Aircraft
Reference : X
Make Model Name : EMB ERJ 170/175 ER/LR
Mission : Passenger
Component
Aircraft Component : Fan Blade
Person
Reference : 1
Events
Assessments
Narrative: 1
I removed and replaced number 20 and number 6 fan blades on left engine of aircraft, and
I believe I may have put the wrong blade back into the number 6 position. I had both new
and old blades in my box and might have mixed them up.
I was speaking to another mechanic and possibly mixed up the blades. [I need] to double
check and even triple check serial numbers off parts being installed.
Synopsis
A maintenance technician described the conditions that contributed to the installation of an
incorrect fan blade.
ACN: 1293413 (15 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : SA-227 AC Metro III
Mission : Passenger
Component : 1
Aircraft Component : Powerplant Fire Extinguishing
Component : 2
Aircraft Component : Electrical Wiring & Connectors
Person
Reference : 1
Function.Maintenance : Other / Unknown
Events
Assessments
Narrative: 1
Maintenance personnel were instructed to [remove and replace] the #1 engine fire bottle
that was due for scheduled maintenance. [The] acting lead mechanic called and stated
that during the fire bottle change on the aircraft, power was applied and the fire bottle was
discharged. Upon investigation it was found that the power and the ground wires on the
fire bottle squib had been swapped and the squib was not wired properly. During
investigation the mechanic performing the work stated that the wires were pre labeled but
the following day when another fire bottle was installed no labels were noted on the wires
and a full run down of the wiring print had to take place prior to installing the replacement
bottle. Mechanic was counseled on the need to label everything removed no matter how
small it may be.
Callback: 1
The reporter confirmed that the fire bottle does not have a conventional connector for the
squid. It has individual wires that are disconnected and reconnected independently.
Synopsis
Maintenance Technician reported that when electrical power was reapplied following the
routine replacement of a Metroliner engine fire extinguisher bottle, the bottle was
unexpectedly discharged. He revealed that wires had been incorrectly connected due to
mislabeling of the wires.
ACN: 1292485 (16 of 50)
Time / Day
Date : 201509
Place
Aircraft
Reference : X
Make Model Name : Commercial Fixed Wing
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Exterior Pax/Crew Door
Person
Reference : 1
Location In Aircraft : Door Area
Cabin Activity : Boarding
Function.Flight Attendant : Flight Attendant (On Duty)
Events
Anomaly.Deviation - Procedural : MEL
Result.General : Release Refused / Aircraft Not Accepted
Assessments
Narrative: 1
I noticed the assist bottle at door 1L lower than minimum recommendation. I then looked
at all 4 doors which also were lower than required for aircraft airworthiness. I contacted
the captain to contact mechanics and verify pressure on all doors. C/S (Customer Service)
came onboard and asked if he could board. The pilot, not putting two and two together
said yes. I interjected and said that they may have to fill door 1L and it was the only
egress door available. The pilot agreed and we held boarding until mechanics could verify
pressure on all doors. Initially, the mechanic came onboard and began to tell me that it
was not my job (onboard - as he wrote on the release later). The mechanic (who in my
opinion was not familiar with the system, dismissed the issue (implying it would take over
2 hours to fill all bottle - when I know in fact, it takes about 10 minutes for each bottle, by
saying all doors were good). Something that is not only irresponsible, but criminal and his
license should be suspended for dismissing some sensitive item and signing off on an item
in which was not good to fly. At that time, the captain with knowledge of aircraft
maintenance, became intrigued as new to the Airbus (previous Boeing pilot). He asked me
and I explained how the temperature gauge and the table all plays a part on determine
which level each door bottle should be. He then grabbed his calculator and a flash light
and proceeded to examine the door himself. He then looked at all 4 doors and agreed that
they were below minimum. Since the mechanic at this time had already signed off as good
to fly. The captain called maintenance and advised that they needed to bring him the table
indicating the aircraft was good to fly. About 1/2 hour later, three mechanics came on
board with the specifications on the doors. The pilots and mechanics discussed the gauge
and soon it was clear that ALL 3 mechanics did not know how to read the gauge and were
seeing pressure above of what it was - I have pictures. The pilot noticed that they could
not agree, and drew a picture of the gauge and proceeded to explain how the mechanics
were not reading the gauge accurately. They did not agree and left the aircraft. Not saying
anything, when the captain inquire they did not respond. Later on, the captain called
[operations] again and had to refuse the aircraft. The mechanics never came back. A
problem that could have been resolved in 1 hour was now over 105 minutes later. Pilot
from the pilots' office came in and the captain explained the problem. Later the captain
asked the first officer to look at the gauge and see if he would agree with the needle
marking. The first officer looked at the gauge and also confirmed that in fact the needle
was what it was told to the mechanics. Ops found us another plane. What transpired next
is not only irresponsible but also criminal. By now C/S, and Ops had changed shift and this
is the only thing I would say made they think the aircraft was air worthlessness. Ops
scheduled the aircraft to fly to [another destination], now, mechanics had already signed
off on the aircraft and done nothing else but disappearing. Customer Service were new
and they had no idea on what was going on. The captain told the new captain of the
problem. But since we left, we can only hope the new pilot convinced the mechanics to fill
the assist bottles. Later we checked and found out that the aircraft left. We did not know if
it was fixed or left be. The negligence of these mechanics caused a chain reaction of
failures that could cost someone's lives some day and for that reason all three should be
reprimanded for their negligence and lack of knowledge on this aircraft.
Synopsis
Mechanics and Captain disagreed about the gauge display for the exit doors' pneumatic
charge. Different aircraft assigned.
ACN: 1291853 (17 of 50)
Time / Day
Date : 201508
Aircraft
Reference : X
Make Model Name : B767-300 and 300 ER
Flight Plan : IFR
Mission : Cargo / Freight
Person
Reference : 1
Location Of Person.Aircraft : X
Events
Assessments
Narrative: 1
I was assigned to work on aircraft to troubleshoot deferrals [Deferral No. 1] and [Deferral
No. 2] per FIM 27-62-01. I attempted the operational test per AMM 27-62-00-715-002.
This test failed. I then performed the B.I.T.E. of the SAC. This test has 2 levels one being
the auto test, the other being the rig test. The rig test failed. At that point I re-deactivated
the auto spoiler system as it was when the aircraft arrived. I was not aware of MIB 6-27-
15-08 which explains the rig test bite of the SAC. Consequently the spoiler handle was
restricted the spoiler handle movement to 50% travel. I had tested the spoiler handle
operation prior to troubleshooting but neglected to do so after troubleshooting.
Synopsis
B767 Maintenance Technician was assigned the task of clearing a spoiler deferral, but was
unable to do so. The MEL was reinstated, but the spoiler handle was not tested and the
aircraft was dispatched with the spoiler restricted to 50% of normal.
ACN: 1291474 (18 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Component : 1
Aircraft Component : Engine Oil Seals
Manufacturer : General Electric GE CF34-8
Component : 2
Aircraft Component : Generator Drive
Person : 1
Reference : 1
Person : 2
Reference : 2
Events
Anomaly.Deviation - Procedural : FAR
Anomaly.Inflight Event / Encounter : Other / Unknown
Result.General : Flight Cancelled / Delayed
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Chart Or Publication
Narrative: 1
August 2015. In ZZZ, myself Aircraft Maintenance Technician (AMT X) and AMT Y, during a
Service Check found a leak from the Integrated Drive Generator (IDG) on the Left-hand
Engine. While changing the IDG carbon seal, documents and references were
misunderstood. The distractions inside the Hangar aided in misplacement of the O-Ring.
The work interruptions from Management distracted us from the task at hand. We
preformed the Leak Check and Operational Check and found everything to be within limits.
Nothing seemed unusual and we signed off the aircraft. The following day, it was brought
to our attention we had placed the O-Ring in the wrong place. While we were discussing
this, the aircraft lost oil from the Left Engine and made an emergency landing.
I would suggest more descriptive [maintenance] illustrations. A new Warning added to the
Maintenance Manual, or internal document added. Availability to faster, more reliable
access to manuals. Better training on (IDG) carbon seal replacement.
Narrative: 2
Aircraft Maintenance Technician (AMT X) and I (AMT Y), were installing a new carbon seal
on the IDG on Engine One. During that process, we put a seal in the wrong location. We
misinterpreted the diagram depicting where the seal went. Throughout this process we
had to keep going back to the [Maintenance] Manual to print out sub-tasks using
computers that are exceptionally slow, as well as endure many interruptions/inquiries at
the hands of Management which added to our distraction. After installation, we performed
the Leak Check in accordance with the Maintenance Manual and there were no leaks so we
did not realize our error at the time. During discussion about the project, Supervision
found that we had incorrectly installed the O-Ring. By the time we discovered this fact it
was the following day, (the mistake happened the day before). As the lines of
communication to right this wrong had been opened, the aircraft lost the oil on the Left
Engine most likely due to our mistake. The aircraft subsequently performed an emergency
landing.
It was easy to misinterpret the diagram in the Maintenance Manual. The interruptions due
to slow network access to the online Maintenance Manual and repeated Management
interruptions added to the situation.
Synopsis
After their CRJ-200 aircraft had departed, two Aircraft Maintenance Technicians realized
they had installed a new carbon seal O-Ring at the wrong location on # 1 Engine
Integrated Drive Generator. # 1 Engine lost all oil in flight. Distraction, inadequate and
easy to misinterpret maintenance diagrams, work interruptions from Management, lack of
training and experience and a slow on-line Maintenance Manual program were noted as
contributors.
ACN: 1290978 (19 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Make Model Name : A320
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Component : 1
Manufacturer : Airbus
Component : 2
Aircraft Component : Landing Gear Indicating System
Person : 1
Reference : 1
Person : 2
Reference : 2
Experience.Maintenance.Lead Technician : 8
Events
Result.Flight Crew : Returned To Departure Airport
Assessments
Narrative: 1
A320 Aircraft has a recurring landing gear fault. This time the fault occurred in ZZZ1 and
was made a Deferred Maintenance Item (DMI) in ZZZ1. Aircraft ferried to ZZZ with the
landing gear lock down. Confirmed the aircraft was in the non-MEL configuration before
starting work for the L/G not unlocked ECAM Message. The right landing gear retract
actuator was ultimately removed and replaced. After all the operation checks were
completed and all cockpit indications were normal, cleared DMI for the Landing Gear
Indication System. The aircraft took off from ZZZ and returned to the field for FLT L/G
Down indication after gear retraction. Aircraft restricted & advised to 235 knots ECAM
message per flight crew and log book entry.
After removing and replacing flight controls, landing gear components etc.. after
inconvenient chronic or recurring faults, no Test flights are required by our Air Carrier.
Inadvertently causing major anxiety and inconveniencing our paying passengers. Prior
experience with other operators, a Test Flight would be required before the aircraft was
returned to revenue flight.
Narrative: 2
Aircraft had multiple crew reports for the Right Main Landing Gear (MLG) not uplocked
ECAM message upon gear retraction. The fault was worked in ZZZ2 and made a few
flights, then the fault returned while the aircraft was in ZZZ1. The Landing Gear Indication
System was deferred per the MEL by Maintenance team in ZZZ1. Request was made to the
company to send the aircraft to our Maintenance facility in ZZZ3 for this repeat problem.
They have the proper facility and tooling. Aircraft was Maintenance Ferried to ZZZ with the
gear lock down only because we had jacks. No facility and no tools for the job. We work in
a Line environment on an un-level ramp and had to jack the aircraft high enough to
preform gear swings and trouble shoot the Landing Gear Retract System in an AOG
situation on the flight line.
Company sent a retract actuator, but the paperwork was incomplete. By the Second night
we received loaner tooling from another Operator and a replacement actuator from Airbus
which had paperwork issues as well. Late into the shift and after working multiple other
aircraft, the paperwork issues were resolved and the actuator was released to
maintenance to install. The right main landing gear retract actuator was removed and
replace per the Trouble Shooting Manual (TSM) and Aircraft Maintenance Manual (AMM).
All operational and leak checks and cockpit indications were normal with the aircraft on
jacks. The DMI was cleared by the replacement of the retract actuator. The aircraft took
off from ZZZ on a revenue flight and the cockpit crew reported an ECAM Advisory Message
FLT L/G DOWN indication after retraction and restricted advised to 235 knots. Crew
returned to the field. Upon further trouble shooting found the L/G DOWN VMO/MMO
selection switch (22FP) on the 188VU panel in the aft E&E bay was inadvertently left in the
L/G down position. Reset L/G DOWN VMO/MMO selection switch (22FP) to the L/G normal
position. Messages cleared. Due to time constrains and pressure to return the AOG aircraft
to service the (22FP) Switch was overlooked when clearing the DMI.
Synopsis
Two Aircraft Maintenance Technicians reported recurring Right Main Landing Gear (MLG)
L/G Not UNLOCKED ECAM faults on an A320 aircraft. Aircraft ferried to a Line Maintenance
Station with limited resources. Right MLG Retract actuator replaced. No Flight Test
required. Aircraft departed but returned to field with ECAM Advisory message FLT L/G
DOWN. Found the L/G DOWN VMO (Maximum Operating Speed Limit)/MMO (Maximum
Mach Operating Speed) selection switch (22FP) on the 188VU panel inadvertently left in
the L/G down position. Reset switch to L/G 'Normal' position.
ACN: 1289759 (20 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Daylight
Aircraft
Reference : X
Aircraft Operator : Corporate
Make Model Name : Citation Excel (C560XL)
Component : 1
Aircraft Component : Gear Up Lock
Manufacturer : Cessna
Component : 2
Person
Reference : 1
Reporter Organization : Corporate
Events
Assessments
Primary Problem : Chart Or Publication
Narrative: 1
During Post Maintenance Checklist Technician found Left-Hand MLG Uplock Hook with worn
bushing. This is the third time in a month we have seen this issue. I recalled when we did
the Phase 1-4 inspections, [we did] a specific task to inspect the uplocks. I checked the
Maintenance Manual and found Task XXXX001 Uplock Detailed Inspection is to be
performed every 300-hours. I performed a search in [our] Maintenance/Inventory
Tracking Program and the Approved Aircraft Inspection Program (AAIP) and cannot find
the task anywhere. It is my belief that since we have been doing the Phase-A and Phase-B
Inspections that this task has been overlooked.
Recommend that Task Card XXXX001 Uplock Detailed Inspection needs to be incorporated
into some kind of scheduled maintenance event.
Synopsis
An Aircraft Maintenance Technician reported finding a third Cessna CE-560XLS aircraft in a
month with Main Landing Gear Uplock Hook bushings worn during their Post Maintenance
Checklist inspections. Technician believed that since they have migrated from doing Phase
1-4 Inspections to performing Phase-A and Phase-B Inspections, the Uplock Detailed
Inspection Task has been overlooked.
ACN: 1289753 (21 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Ferry
Component
Aircraft Component : Engine Driven Pump
Manufacturer : GE/Snecma CFM-56
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations : Equipment / Tooling
Narrative: 1
August 2015. Began with an XA:00am morning flight from ZZZ4. [With departure] show
time [eight hours] later. Aircraft arrived in ZZZ at XI:20. Sat in ZZZ for four hours then
ferried B737 Aircraft X to ZZZ1 to replace another B737, Aircraft Y. Arrived in ZZZ1 early
[the following morning]. A 20-hour and 40-minute day. We got to the hotel and I was
finally able to sleep.
After 6:30 hours of sleep, I received a phone call from Maintenance Control, "A mechanic
is on his flight from ZZZ2, get out and start taking Aircraft Y apart so we can get this
plane fixed". I got up, dressed, packed up and went down and had breakfast. I checked
out of the hotel and went out to repair Aircraft Y. The mechanic and I got the plane fixed
and ready for a late night departure. 15 hours and 35 minutes after my wake up.
Approximately early afternoon it started to rain. It rained off and on for the rest of the
day. After the repair was complete and an engine run for a leak check, the cowlings had to
be closed. I laid under the engine to close the C-Cowls and Main engine cowling. Now I'm
soaking wet from head to toe on my back. Wet ramp. We closed up everything, put the
tools away, returned borrowed tools and I boarded the plane for a Ferry to ZZZ3. I
changed my clothes in flight. A 6.5 hour flight from ZZZ, early morning arrival. I secured
Aircraft Y and went to hotel. A 22 hour and 45 minute day.
On arrival at the hotel that morning, I was told that our reservations were for [the day
before] and since we did not check in, our reservations were cancelled. The Crew rooms
were re-booked, but mine was not. Since mine was not, I had no room. I had to wait for a
room to be available and cleaned before I could get a room. Two hours later I got a room.
Three hours of sleep and I'm back out on Aircraft Y to do a Power Trim (PT) before we go
to ZZZ4. A scheduled late afternoon departure. We were late. We left after midnight, the
following day.
On arrival in ZZZ4, I called the hotel and find out that my reservation was for the day
before. Cancelled again. I called Crew Scheduling and they re-booked my room at the
Hotel ZZZ5. So I limo'd to the hotel. I arrived late night. After two hours of sleep, I woke
up for my commercial flight home. I tried to check in on-line. There is a problem, I must
call the airline. Once again my flight reservation was for the previous day, not the day
later [which is what I was trying to fly]. It was cancelled. I had to pay a $50.00 re-booking
fee. My flight was re-booked and I was on my way home.
When the schedule changes, for whatever reason, the Crews have someone there 24/7 to
change their itinerary. When Scheduler X is off, there is no one to change the Mechanics
itinerary. They gladly do it, they just have to be told that there is a Mechanic with the
crew.
My first two 'Off' Days were spent recuperating from a serious lack of sleep the previous
three days. This is a personal inconvenience because it interferes with my days off. 14-
days on the road plus two days resting means I'm working 16-days. But that is a personal
inconvenience. If this had happened on Day-2 or -3 of a trip it would be a much different
story. When would a Mechanic have time to rest from this type of schedule? It doesn't
happen often, but it does happen.
Our schedules are much tighter than pilots and flight attendants. When there is a schedule
change or broken airplane, if our Scheduler is not around to see that our itinerary is
changed, it won't get changed unless we call them ourselves. Kind of hard to do when you
have a Fuel Pump Package in your hands. It weighs 200 pounds.
Please have someone inform Scheduling that if they re-book the crews could they please
ask about a mechanic. Just to see if maybe a Mechanic is affected by the schedule change
too. It would be greatly appreciated by those that get these planes repaired. Thank you.
Synopsis
An Aircraft Maintenance Technician (AMT) working as an on-call Air Carrier Technical
Representative describes his excessively long, irregular work days, ever changing work
hours, lack of adequate support for re-scheduling hotels and fatigue from lack of sleep.
ACN: 1289750 (22 of 50)
Time / Day
Date : 201508
Place
Aircraft
Reference : X
Component : 1
Aircraft Component : Fan Disc
Component : 2
Aircraft Component : Fan Blade
Person
Reference : 1
Events
Assessments
Narrative: 1
While trying to remove N1 fan blade per given Aircraft Maintenance Manual (AMM), tool
marks [were] made on [Fan] disk thus requiring unscheduled engine replacement. No
exact tooling listed in given AMM to remove N1 Fan blade shim/keeper weights and using
hand to work is not really possible.
[Recommend] Tool [be] made or listed [in AMM] to remove N1 Fan blade shim/keeper
weights and added to AMM 72-21-02 and listed in required tool section. Also, [add
maintenance] NOTE: given the importance on not having damage to Fan blade disk due to
tooling marks.
Synopsis
An Aircraft Maintenance Technician recommended a specific tool be made or listed in the
Aircraft Maintenance Manual for technicians to use to avoid damage to CFM-56 Engine Fan
disks when removing the N1 Fan Blade Shim/Keeper weights. Inadvertent tooling damage
by Technician required unscheduled engine replacement on a B737-900 aircraft.
ACN: 1288221 (23 of 50)
Time / Day
Date : 201508
Place
Aircraft
Reference : X
Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng
Mission.Other
Flight Phase : Taxi
Person
Reference : 1
Location Of Person : Company
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Ground Conflict, Less Severe
Anomaly.Deviation - Procedural : Clearance
Anomaly.Ground Excursion : Runway
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Result.Flight Crew : Regained Aircraft Control
Assessments
Narrative: 1
After holding short at [runway], Control Tower told us that we were cleared to cross
[runway] and expedite as there was another aircraft about to land. I started to advance
engine throttles to expedite runway and saw aircraft getting closer to landing and I heard
my taxi partner saying "go ahead, expedite". I thought we were in danger zone (middle of
runway crossing it) and aircraft was ready for landing. There seemed to be a delay in the
response of the aircraft to accelerate. We wanted to cross the runway and clear the path
for the aircraft to land (and avoid a collision). I lost control of the aircraft trying to clear
the runway. Aircraft did not respond to the right turn, ending on the grassed area. It all
happened very quickly and I found myself in the middle of an expedite situation that
required immediate action. In an aircraft landing situation like this, it would have been
different if the control tower instructed us to wait for the other aircraft to land instead of
clearing us to cross runway and expedite. Another suggestion is to improve taxi/engine
run-up training to include practice for expedite situation.
Synopsis
A Maintenance Technician lost control of an aircraft following an expedited taxi across a
runway with approaching landing traffic.
ACN: 1287823 (24 of 50)
Time / Day
Date : 201508
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : Airbus Industrie Undifferentiated or Other Model
Component : 1
Aircraft Component : Data Transmission and Automatic Calling
Component : 2
Aircraft Component : Tablet
Manufacturer : IPAD
Component : 3
Aircraft Component : Minimum Equipment List (MEL)
Person
Reference : 1
Human Factors : Human-Machine Interface
Events
Assessments
Contributing Factors / Situations : MEL
Primary Problem : Equipment / Tooling
Narrative: 1
August 2015, I was called onto an aircraft due to a 'Sys 2 Reg' fault. Deferred item
through Lead and Maintenance Operations Control (MOC). Aircraft blocked out and I
connected the MEL through IPAD/Digital communications under 'deferred Aircraft
Maintenance Technician (remove from work)'.
Upon arriving to work four days later, I was informed of the inadvertent fact [clearing] of
the MEL. I explained the events that took place four days earlier to my Manager and senior
Manager and came to the conclusion that there was an IPAD digital communication
malfunction. I believe we can prevent this event from happening again by fixing the
IPAD/Digital communications [software] issues. IPAD facted [cleared] MEL.
Synopsis
An Aircraft Maintenance Technician recommended his Air Carrier fix the malfunctions with
their IPAD/Digital communication software program that cleared a 'System-2 Regulator'
fault discrepancy instead of deferring the Logbook item.
ACN: 1282992 (25 of 50)
Time / Day
Date : 201507
Place
Environment
Light : Daylight
Aircraft : 1
Reference : X
Maintenance Status.Required / Correct Doc On Board : N
Aircraft : 2
Reference : Y
Component : 1
Aircraft Component : Circuit Breaker / Fuse / Thermocouple
Component : 2
Aircraft Component : Fuel System
Component : 3
Aircraft Component : Aircraft Documentation
Person
Reference : 1
Analyst Callback : Attempted
Events
When Detected.Other
Assessments
Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part
Narrative: 1
We Cannibalized [Robbed] a GFI relay from Aircraft X, a B747-400, for Aircraft Y, another
B747 without any trouble. After I had removed the relay from Aircraft X, my Lead told me
to install the unserviceable relay from Aircraft Y into Aircraft X so that they could defuel
the plane. We recently updated to the GFI System to comply with an Airworthiness
Directive (AD) that is due August 2015. I voiced my thoughts which were that we
shouldn't install an unserviceable part of any kind into the system to which my Supervisor
said to just do it so they can defuel the plane.
After I refused to install it, it was tasked to someone else who installed it and then the
maintenance went undocumented, and they preceded to defuel the tank. It has since been
removed and sent out for repair and still went undocumented that it was ever installed on
Aircraft X.
This is a massive safety risk due to the GFI system is meant to disrupt power to the fuel
pump in the case of a load imbalance, lost [electrical] phase, etc that could possibly cause
for an ignition source inside the fuel pump, within the tank. My Lead claims its ok to do
this because the plane is on the ground.
Synopsis
An Aircraft Maintenance Technician reported about a potential safety risk and improper
maintenance documentation practices after his Lead and Supervisor directed him to install
a faulted and unserviceable GFI Relay into a B747-400 aircraft that needed to be defueled
for maintenance. GFI was part of an airworthiness directive to disrupt electrical power to
fuel pumps in a fuel tank.
ACN: 1282664 (26 of 50)
Time / Day
Date : 201507
Place
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Cowling/Nacelle Fasteners, Latches
Problem : Design
Person : 1
Reference : 1
Person : 2
Reference : 2
Events
Assessments
Narrative: 1
An A check was being performed and completed on the [next] morning. The aircraft had
some remaining open discrepancies, so the aircraft was finished up and released on the
[following] morning. Upon the aircraft leaving it had its RH engine upper nose cowl come
loose and depart the aircraft.
The mechanic working the engines that night had me take a look before closing to ensure
all tools rags and equipment was removed. At that time I went back to the office to
complete my paperwork and paperwork/aircraft book closing responsibilities.
Approximately 30-45 minutes later I went back out to do my walk around to see it closed
up. I walked around to ensure all panels, latches, and cowls were closed up. Then I went
on the staircase and took a peek up top to ensure the cowls were installed and no tools
and equipment were left on top of the aircraft. Then the aircraft got towed outside to
complete ops checks and engine runs. The aircraft was towed back in after completion to
check the engines for leaks. No leaks were noted, the lower core cowls were open then
closed back up. I did a final walk past to ensure the core cowls have been closed.
Viewing the upper cowls from the portable staircase provides a good visual to see that the
cowls are installed. But not for a detailed visual check of fasteners. From that location the
cowls appeared to be installed and had no obvious defect.
Would need to do a detailed visual check of all the fasteners and not that just the cowls
are installed.
Narrative: 2
I was working on the RH engine doing an inspection and servicing. Part of the task was to
remove the upper and lower nose cowls. After performing all scheduled and unscheduled
maintenance on the engine, I reinstalled both the upper and lower nose cowls as required.
I reinstalled all of the required fasteners and then had the installation verified by an
inspector. The aircraft did not leave until [2 days later]. Shortly after takeoff, the pilot had
to shut down the RH engine and upon landing it was found that the upper nose cowl had
departed the aircraft and the lower nose cowl was severely damaged as well as other area
of the engine and tail.
This part of the aircraft has a long history of failure. The FAA has issued an Airworthiness
Directive (AD) to modify the nose cowls to strengthen and prevent these incidents from
happening. This AD was performed on this aircraft and yet it still failed. I installed all of
the hardware, which was verified and yet it still failed.
I think that maybe there should be a more stringent verification process. Maybe after
installing the nose cowls another mechanic or lead should verify the installation before
going to the inspector. This would provide at least a third set of eyes before dispatching
the aircraft. I know that this is what I will be doing, as well as maybe taking pictures of
the installation.
Synopsis
A Maintenance Technician and Inspector describe the events that led up to the loss of
engine upper cowling from CRJ-200.
ACN: 1281886 (27 of 50)
Time / Day
Date : 201507
Place
Aircraft
Reference : X
Component
Person
Reference : 1
Events
Assessments
Narrative: 1
I was given an assignment to complete when I arrived for my work shift. My lead asked
me to look into [a specific] Non-Routine.
I looked up the paperwork to repair the conduit as requested by my lead, and went out to
inspect the extent of the damage. After I inspected the extent of the damage, I let my
lead know that the conduit required replacement In Accordance With (IAW) the Boeing
Standard Wiring Practices Manual (BSWPM). He told me it's okay just repair it, to which I
refused to do because the manuals says that any damage MORE than 25 percent of the
circumference requires replacement. He told me I just need to do it because the Line
Maintenance Manager told him to get it repaired. At this point I handed my lead the
paperwork and said I would not repair it, so I was put on another task.
My lead proceeded to instruct one of our unlicensed mechanics to repair it by placing

Teflon tape inside the conduit and filling it with red silicone and taping the outside of the
conduit up.
My lead annotated on the paperwork the following:
1) ASSESSED DAMAGE TO L/H BODY GEAR CONDUIT, FOUND TO MEET CONDITIONS FOR
REPAIR AS DESCRIBED PER BSWPM
2) NO DAMAGE EXISTS TO WIRES OR CONVOLUTED TUBE AS DESCRIBED IAW BSWPM
3) REPAIRED METAL OVERBRAID WITH NO DEFECTS IAW BSWPM
Synopsis
A Maintenance Technician disagreed with a Lead Technician on the use of an electrical
conduit repair based upon the extent of the damage.
ACN: 1280088 (28 of 50)
Time / Day
Date : 201504
Place
Environment
Work Environment Factor : Poor Lighting
Aircraft
Reference : X
Aircraft Operator : Fractional
Make Model Name : Citation Excel (C560XL)
Mission : Passenger
Component : 1
Aircraft Component : Speed (Rate Sensing)
Problem : Design
Component : 2
Aircraft Component : Horizontal Stabilizer Control
Person
Reference : 1
Events
Assessments
Narrative: 1
I replaced an airspeed switch for a stab mis-compare squawk. I performed an ops check of
the two position horizontal stab system I/A/W CE560XL m/m chap. 27-40-00 and believed
the system checked ok per the maintenance manual. [Seven weeks later] I was contacted
by my supervisor and advised that the aircraft was in inspection and during the
operational check of the horizontal stab system it was discovered that the airspeed switch
failed the operational check and was installed incorrectly.
After being made aware of this instance I was counseled on paying attention to the proper
installation of components and indications during the operational checks. The company
made a training PowerPoint for its employees to bring awareness to this issue and other
components that can be installed incorrectly. Also a technical publication change request
was submitted by Cessna from a request made by QAC to note/warn of the possibility of
this switch being able to be installed incorrectly.
When I installed the switch and performed the ops check I believed it to check good IAW
the MM and would not have released the aircraft otherwise. I have learned to pay closer
attention to the components before and after install to try and assure this does not happen
again.
Synopsis
A Maintenance Technician was advised that the part he replaced several months earlier
had been installed incorrectly. The fault was identified by the failure of the horizontal
stabilizer operational check during routine inspection.
ACN: 1279377 (29 of 50)
Time / Day
Date : 201507
Place
Aircraft
Reference : X
Make Model Name : Learjet 35
Mission : Passenger
Component
Aircraft Component : Turbine Engine
Person : 1
Reference : 1
Person : 2
Reference : 2
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 10000
Experience.Flight Crew.Last 90 Days : 70
Experience.Flight Crew.Type : 4000
Person : 3
Reference : 3
Events
Assessments
Contributing Factors / Situations : Logbook Entry
Narrative: 1
I had inadvertently returned a Learjet to service on many occasions with questionable
inspection records for the T Piece Seal on an [engine]. The inspection record for this part
was missing an inspector's stamp, but had been signed by the tech who had performed
the inspection. I was alerted to the discrepancy by the overhaul facility and was later
contacted by their vendor's FSDO. During our discussion, the inspector and I came to the
conclusion that the part had sufficient life remaining to make it to the next Major Periodic
Inspection (MPI) Inspection because it had been inspected previously, before installation
on another engine, and had sufficient life remaining until a new inspection would have
been due if the part had stayed on the original engine. I called my operator's Principle
Maintenance Inspector (PMI) for concurrence and it was concluded that the logic was
sound and we could continue to fly the engine until the next MPI Inspection was due. This
afternoon, my operator's Director of Maintenance called me and to inform me that our
Principle Operations Inspector (The previous PMI who had concurred with the vendors PMI
had moved to another assignment) had questions about the airworthiness and
documentation for this part. Together, the PMI and our Director of Maintenance
determined that the aircraft would be considered not airworthy. In my conversation with
the Director of Maintenance, he said that our PMI had determined the week before that
this discrepancy did not call in to question the airworthiness of the part. I could not
provide any documentation of the conversations with FAA inspectors from when this
discrepancy had originally occurred. The FAA is not prepared to help us make a
determination of the airworthiness of this part in any other way but to open an
investigation.
Narrative: 2
I had inadvertently flown a Learjet on many occasions with questionable inspection
records for the T Piece Seal on an [Engine]. The inspection record for this part was missing
an inspector's stamp, but had been signed by the tech who had performed the inspection.
I was alerted to the discrepancy by the overhaul facility, and was later contacted by their
vendor's FSDO. During our discussion, the inspector and I came to the conclusion that the
part had sufficient life remaining to make it to the next Major Periodic Inspection (MPI)
Inspection because it had been inspected previously, before installation on another engine,
and had sufficient life remaining until a new inspection would have been due if the part
had stayed on the original engine. I called my operator's Principle Maintenance Inspector
(PMI) for concurrence and it was concluded that the logic was sound and we could
continue to fly the engine until the next MPI Inspection was due. This afternoon, my
operator's Director of Maintenance called me and to inform me that our Principle
Operations Inspector (The previous PMI who had concurred with the vendors PMI had
moved to another assignment) had questions about the airworthiness and documentation
for this part. Together, the PMI and our Director of Maintenance determined that the
aircraft would be considered not airworthy. In my conversation with the Director of
Maintenance, he said that our PMI had determined the week before that this discrepancy
did not call in to question the airworthiness of the part. I could not provide any
documentation of the conversations with FAA inspectors from when this discrepancy had
originally occurred. The FAA is not prepared to help us make a determination of the
airworthiness of this part in any other way but to open an investigation.
Narrative: 3
I am a Director of Maintenance for a Corporate Operator. I am self-disclosing an issue
[discovered] during a review of the No. 1 engine log books, I discovered a lapse in
documentation affecting the record keeping of the engine's compliance status. I conducted
a fact finding mission that revealed the left engine had a part installed at its last overhaul
Core Zone Inspection (CZI) that might have not been inspected properly. The issue had
been reported to the FAA, the manufacturer, and my employer. After a careful review of
the documents and conferring with our FAA. Principal Maintenance Inspector, we agreed
the manufacturer had determined the part was not due an Nondestructive Testing (NDT)
inspection for another 1,700 hrs. and the next Major Periodic Inspection (MPI) inspection
would be due 1,400 hrs. from the time the part was installed. However, the manufacturer
decided to recommend the engine be removed from the aircraft and the part be NDT
inspected in order to bring it in line with the rest of the parts that get the same NDT
inspection during every CZI. This decision came in a letter of 'No Technical Objection'.
That recommendation is what our current Principle Maintenance Inspector is relying on to
determine if a compliance violation has occurred. Once I became aware of the lack of
documentation in the aircraft records addressing the issue after Honeywell's
recommendation, I grounded the aircraft for maintenance and am currently lining up a
vendor that will support our aircraft to resolve the matter.
The overhaul shop's records indicate the part was NDT inspected, but one internal tally
sheet was missing an inspector's stamp. We were provided that sheet as well as another
internal document where the mechanic wrote in his own cursive handwriting that he had
performed the inspection and an inspector stamped the document indicating it had been
complied with.
We were also provided a Form 8130-3 releasing the part for airworthy status. That
document is still in force and has not been rescinded to my knowledge. I believe the part
was inspected and is airworthy but have decided to ground the aircraft to remove all doubt
about the part's compliance.
Synopsis
A Director of Maintenance and a pilot/mechanic reported that they had been advised of a
missed inspection signoff for an internal engine component, but that in discussion with a
FAA Principal Maintenance Inspector, the part was airworthy with the time remaining.
Later, the conclusion was questioned by another Principal Maintenance Inspector and was
under investigation.
ACN: 1278743 (30 of 50)
Time / Day
Date : 201507
Place
Environment
Light : Dawn
Aircraft
Reference : X
Mission : Passenger
Person
Reference : 1
Events
Assessments
Narrative: 1
Aircraft supervisor approached me in my office and said he needed the inspector slot on
log page for the #1 engine change signed for. I asked him if all the paper work was
complete and the job was complete and his reply was yes and that the aircraft was at the
terminal being loaded for its [next] trip. After I signed the log book I went to review the
engine change paper work package when I discovered the Engine change installation task
was not completed. By the time this discovery took place the aircraft already [departed].
Synopsis
A Maintenance Inspector discovered that the Maintenance Supervisor was incorrect when
he reported that all of the engine change paperwork was completed when he requested
the final signoff.
ACN: 1278430 (31 of 50)
Time / Day
Date : 201507
Place
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Make Model Name : MD-82
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Climb
Airspace.Class B : ZZZ
Component
Aircraft Component : Nose Gear Door
Person : 1
Reference : 1
Person : 2
Reference : 2
Function.Flight Crew : Pilot Flying
Person : 3
Reference : 3
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Events
Result.Flight Crew : Took Evasive Action
Assessments
Narrative: 1
Called out to aircraft had several items. Began with nose gear steering problem, removed
tow bar steering pin, opened gear doors, [the] other mechanic upstairs turned on
hydraulic moved tiller, checked nose gear for proper operation, inspected tires wheels
deflectors, all nose gear components, all checks good. Went upstairs to see if anything was
felt on tiller became distracted with several interior items and forgot to close doors.
Shorthanded, distracted with interior items trying to save boarding time.
Needed to stay on job I started. No excuses. Made mistake trying to do too many tasks at
once.
Narrative: 2
Upon gear retraction, the aircraft had a shudder throughout the plane. Gear handle was
placed back down and shudder stopped. Accelerated to 200 knots and the shudder
returned. Slowed to 170 knots for the remainder of the flight. [Completed the QRH] and
landed. Stopped straight ahead until the gear pins could be installed. Taxied to the gate.
Narrative: 3
We gave the flight attendants [a] briefing and notified Ops. We had a smooth landing and
stopped straight ahead on the runway and waited for maintenance to pin the gear and
proceeded to taxi to a gate.
Synopsis
A distracted and overworked MD-82 Mechanic forgot to close the nose gear door following
a maintenance procedure the previous evening. After takeoff the next morning a severe
hydraulic system shudder during gear retraction caused the flight crew to lower the gear
and return to the departure airport.
ACN: 1278065 (32 of 50)
Time / Day
Date : 201504
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : B737 Undifferentiated or Other Model
Flight Plan : IFR
Mission : Passenger
Component : 1
Aircraft Component : Indicating and Warning - Lighting Systems
Component : 2
Person
Reference : 1
Qualification.Maintenance : Avionics
Events
Assessments
Narrative: 1
April 2015. [Company] Air Carrier B737 at ZZZ. Pilot reported that the "parking brake light
illuminates intermittently at cruise (park brake handle -off)." Mechanic facted [closed] out
the item with (replace parking brake light bulb). And then the item was dated, signed, and
company employee number documented in Logbook.
[Company] General Procedure Manual (GPM) XX-XX-2 Responsibility and Authority.

The Mechanic that does the maintenance or repair must use the applicable technical data,
judgment, experience and knowledge to make a decision of airworthiness.
[Company] General Procedure Manual (GPM) XX-XX-3. Responsibility for Maintenance

Operations.
Maintenance discrepancies that do not have a related manual procedure for repair will be
repaired with sound maintenance practices in accordance with industry standards,
experience, and good judgment and will have the applicable signature document with the
complete description of the work done. The company will not compromise aircraft safety
for any reason. This includes flight schedules.
Federal Air Regulations:

43.5 Approval for return to service after maintenance, preventive maintenance, rebuilding,
or alteration. No person may approve for return to service any aircraft, airframe, aircraft
engine, propeller, or appliance that has undergone maintenance, preventative
maintenance, rebuilding, or alteration unless
(a) The maintenance record entry required by 43.9 or 43.11, as appropriate, has been
made;
43.7 Persons authorized to approve aircraft, airframes, aircraft engines, propellers,
appliances, or component parts for return to service after maintenance, preventative
maintenance, rebuilding, or alterations.
(b) The holder of a mechanic certificate or an inspection authorization may approve an
aircraft, airframe, aircraft engine, propeller, appliance, or component part for return to
service as provided in Part 65 of this chapter.
43.9 Content, form, and disposition of maintenance, preventative maintenance, rebuilding,

and alteration records (except inspections performed in accordance with Part 91, Parts
125, 135.411 (a) (1), and 135.419 of this chapter).
(a) Maintenance record entries. Except as provided in paragraph (b) and (c) of this
sections, each person who maintains, performs preventative maintenance, rebuilds, or
alters an aircraft, airframe, aircraft engine, propeller, appliance, or component part shall
make an entry in the maintenance record of that equipment containing the following
information:
(4) If the work performed on the aircraft, airframe, aircraft engine, propeller, appliance, or
component part has been satisfactorily, the signature, certificate number, and kind of
certificate held by the person approving the work. The signature constitutes the approval
for return to service only for the work performed.
43.12 Maintenance records: Falsification, reproduction, or alteration.

(a) No person may make or cause to be made:
(1) Any fraudulent or intentionally false entry in any record or report that is required to be
made, kept, or used to show compliance with any requirement under this part.
Callback: 1
Reporter stated he initially thought the intermittent (flickering) Parking Brake Lamp might
have been associated with an anti-skid valve issue. But, he had been around the B737s for
years and suspected the lamp was failing. So he changed the Parking Brake lamp and
signed-off the Logbook item as 'Replaced'. He could not use an Aircraft Maintenance
Manual (AMM) reference in the sign-off, because no procedure exists specifically for
checking the light as functional. An FAA Inspector had been reviewing sign-offs and
questioned the lack of a maintenance reference with the Logbook sign-off. In hindsight,
perhaps he could have referenced their General Procedures Manual (GPM) in the Logbook,
but he thought he had applied good judgment and sound maintenance practices as noted
as acceptable sign-offs in their GPM; especially since the lamp was functioning just fine.
Synopsis
An Aircraft Maintenance Technician (AMT) reports he did not include any Aircraft
Maintenance Manual (AMM) reference in a logbook sign-off for replacement of a parking
brake light on a B737 that had illuminated intermittently at cruise with the parking brake
'off.'
ACN: 1277957 (33 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Night
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Reference : Y
Make Model Name : Commercial Fixed Wing
Mission : Passenger
Component : 1
Component : 2
Person
Reference : 1
Events
Assessments
Narrative: 1
I was tasked with [working several] aircraft with autothrottle inop, hgs (Heads-Up
Guidance System) display inop, L2 window heat inop and engine control light write up
along with the other regular task cards. While working on [aircraft X] I accomplished step
1 (battery replacement) and since there was no part sent for the second step, I then went
to work on [aircraft Y] with window heat and engine control light issues. Meanwhile got
notified that the part for the second step on [aircraft X] (battery charger) had showed up.
Went back to the first plane to complete step 2 for battery charger change. During
removal missed pulling one of the two circuit breakers both labeled battery charger. The
charger cable terminal lug contacted and shorted damaging the contact terminal. Notified
lead and supervisor of the issue immediately. Engineering desk was consulted and came to
consensus to re-terminate a new contact lug or replace the run for that charger cable.
There was a lot of work scheduled for the night. Parts were not all present at beginning of
the shift. While working between the AOG (Aircraft on Ground) write ups for aircraft [X
and Y] I missed pulling one of the breakers labeled battery charger.
Synopsis
A Maintenance Technician neglected to fully remove power from the battery charger,
resulting in shorting of the contact terminal that required replacement.
ACN: 1277063 (34 of 50)
Time / Day
Date : 201507
Place
Environment
Light : Daylight
Aircraft
Reference : X
Component : 1
Aircraft Component : Gear Extend/Retract Mechanism
Component : 2
Aircraft Component : Gear Lever/Selector
Person
Reference : 1
Location In Aircraft.Other
Events
Anomaly.Inflight Event / Encounter : Other / Unknown
Assessments
Narrative: 1
During inspection for a PIREP for a "grinding noise and feel" in the [Landing] gear handle
after a Functional Check Flight (FCF) (previous PIREPs also), I found the landing gear
control cables, in the forward cargo [pit] ceiling outboard side at approximately [frame]
station 300, to be wrapped around each other. This was causing the stiff [gear] handle
and grinding noise. Cables were inspected per Aircraft Maintenance Manual (AMM) and
rerouted, re-rigged per AMM and all operational checks were normal. It appears that a
floor beam repair had been accomplished recently, the cables removed during that
process. [Contributing factor] Failure to properly inspect cable installation. [Recommend]
proper [clearance] "clear to close" and inspection of routing of control cables when
disconnected.
Synopsis
An Aircraft Maintenance Technician (AMT) reports finding the landing gear control cables in
the forward cargo pit ceiling wrapped around each other at approximately frame station
300 on a B767-300 aircraft. Pilots had made several previous write-ups for a stiff gear
handle with a "grinding noise and feel." A floor beam repair had recently been
accomplished that removed the cables. 'Clearance to Close' panels also an issue.
ACN: 1275197 (35 of 50)
Time / Day
Date : 201507
Place
Aircraft
Reference : X
Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Pax Seat
Person
Reference : 1
Events
Assessments
Narrative: 1
Wrong seats installed in Aircraft at the emergency exit row on both sides. The Aircraft over
wing escape had the wrong seats installed forward of the emergency exit. The tray table
blocked the emergency exit and the seats in the emergency exit should have had tray
tables in the arm rest they did not this was also the wrong seats installed at that row.
Synopsis
An MD-80 had normal seats installed in two of the emergency exit seat rows. The seatback
tray tables could block the emergency exits.
ACN: 1274898 (36 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : Regional Jet 900 (CRJ900)
Flight Plan : IFR
Mission : Passenger
Component : 1
Aircraft Component : Pneumatic System - Indicating and Warning
Manufacturer : Bombardier CRJ
Problem : Design
Component : 2
Manufacturer : Bombardier CRJ
Person
Reference : 1
Events
Assessments
Narrative: 1
When I [Maintenance Controller X] came on duty the L BLEED LEAK WARNING was being
reported by phone by the flight crew. I called outstation Maintenance to come to the
aircraft to try to find the cause of the indication. We checked the Maintenance Diagnostic
Computer (MDC) for evidence and found none but ran a Bleed Leak Event Location test.
The results of the test indicated a leak or false indication in the APU bleed air duct
between the APU bulkhead and the Isolation Valve at the Crossover duct. The Mechanic
inspected the duct and bleed [Overheat Warning] loops and could not find any defects. We
then ran the APU at the gate, supplying air for a considerable length of time and could not
duplicate the fault. The aircraft was released with no faults found. An hour or more later
the warning came back. The Mechanic was still in the area so I had the crew shut down
the APU and use an airstart to run the engines. My involvement ended at this point in the
event because I became involved in some other problem. My comment to the Maintenance
Operations and Duty Manager (MOD) at this point was that I suggested we find another
aircraft for the flight because we could not effectively troubleshoot this "warning" problem
without a 'break out box' and some other tooling and parts. I felt we were either proving a
leak in the APU ducting or a false warning in that area at this point. The next thing I knew
the APU was deferred and the aircraft was released.
Maintenance Controller Z told me when I came in for work the next week that he had been
requested to submit a report because the deferral of the APU was deemed inappropriate.
There was a lot of discussion in the office between Maintenance Controller Z and the MOD
as to the correctness of that and I am not sure where that went.
I could not find an acceptable deferral for this fault. The deferrals stipulated that the APU
Load Control Valve (LCV) had to function and in the warning condition, it is forced to
'close'; so in my opinion that is "not working".....This event transpired over several hours
and there was a lot of conversation in the office about how to move the aircraft. My
solution was to replace the aircraft and send a roadtrip because I do not feel that
outstation Maintenance can effectively troubleshoot a warning in this system without
proper tooling and training. I guess I was overruled.
I am submitting this ASRS report. My timeline is not firm and there were a lot of other
problems at the time. And guess what? I came in to work today and we have the same
problem on the same aircraft again. The only difference is the location of the aircraft. It is
even showing the same locations again in the Anti-Ice Leak Detection Controller (AILC)
event location test. Maybe we have a bad AILC? Or we have an actual leak that we have
not located yet. There is a significant lack of knowledge of this system in the Maintenance
Control office and "0" experience working on the system other than Maintenance Controller
Y and myself. Nobody wants to hear what I have to say about it. I am too conservative
and not deemed a "team player" when it comes to these kind of issues.
It is my belief that any time a "warning" occurs in this system it appears to me that if the
system cannot be deferred, it cannot be troubleshot effectively by an untrained, ill
equipped outstation Mechanic "looking it over" and signing it off. If the system is not
deferrable then it should demand a roadtrip supported by qualified mechanics with proper
training and proper equipment and tooling.
Callback: 1
Reporter stated the "break-out box" is an interface tool that allows Maintenance to
troubleshoot the Overheat Warning Detection (A and B) loops via the AILC Controller while
outside of the very tight Avionics compartment on CRJ-900 aircraft. He believes that 90 %
of the reliability issues at the gate involve false overheat warning EICAS messages caused
by the loop sensing element connectors that use steel with ceramic insulators. The ceramic
insulation is prone to cracking and will then bleed electrons, sending spurious, false
warnings of a pneumatic leak through the Bleed Leak Detection System. The warning
loops and connectors start in the Aft Equipment Bay and connect at the fuselage flat
pressure bulkhead using 90-degree angle connectors and then run alongside the length of
the fuselage APU duct, out to the wings, and engine pylons.
Reporter stated that in the aircraft he reported about, two pneumatic leaks were
eventually located at insulated duct clamps connecting the APU pneumatic duct manifold
along the internal fuselage and the other leak was isolated in the Aft Equipment Bay.
Another CRJ-900 recently had three air returns caused by one of the Overheat Warning
loop elements had made contact with a wing anti-ice duct.
Synopsis
A Maintenance Controller reports about events surrounding an inappropriate deferral of an
APU for an EICAS L BLEED LEAK WARNING on a CRJ-900 aircraft at an outstation gate.
Controller also noted the significant lack of knowledge maintenance controllers have of the
pneumatic system, the untrained, ill equipped outstation mechanics, and the lack of
effective troubleshooting the cause of the EICAS warning.
ACN: 1274892 (37 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : EMB ERJ 145 ER/LR
Component : 1
Aircraft Component : Fuel Crossfeed
Manufacturer : Embraer
Component : 2
Aircraft Component : Indicating and Warning - Fuel System
Component : 3
Person
Reference : 1
Events
Assessments
Narrative: 1
On the evening shift ending, June 2015, an EMB-145 aircraft was in ZZZ with a fuel
system MEL (along with other items on the Bill of Work (BOW). The original squawk
indicated that selecting the Fuel Transfer switch on the overhead panel to 'LOW' would
supply fuel not only to engine selected, but also to that side's wing tank. Research
indicated that this would happen selecting 'LOW' fuel in either direction.
A thorough ops check for a lengthy period of time was performed, running APU and both
engines trying to duplicate the squawk, trying all pumps and all combinations of switching.
Completely unable to duplicate the squawk, I cleared the MEL.
HOWEVER, in researching the squawk and MEL, I FAILED to completely review the
Maintenance Procedures for MEL 28-XX-XX. As a result, I failed to properly completely
"de-MEL" the fuel system. It came to my attention early this morning that the Defuel Valve
was found safety wire closed, obviously in that configuration from the original MEL. Failure
to completely research and review all the MEL procedures. In addition to researching a
squawk, COMPLETELY review ALL MEL procedures related to that squawk if same has been
MEL-ed.
Synopsis
An Aircraft Maintenance Technician (AMT) was informed he had failed to completely review
the Maintenance Procedures previously accomplished under MEL 28-XX-XX, when a
Defueling Valve was found still safety wired closed after he had cleared the MEL. The
deferral had noted when selecting the Fuel Transfer switch on the Overhead panel to
'LOW', fuel would be supplied not only to the engine selected, but also to that side's wing
tank.
ACN: 1274216 (38 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
Mission.Other
Component : 1
Manufacturer : Turbomeca Arriel
Component : 2
Aircraft Component : Fuselage
Manufacturer : Eurocopter
Component : 3
Aircraft Component : Aircraft Documentation
Person
Reference : 1
Function.Maintenance : Quality Assurance / Audit
Human Factors : Other / Unknown
Events
When Detected.Other
Assessments
Narrative: 1
An electronic news gathering helicopter was due [for] a 100-hour airframe plus several
hourly engine inspections. Operations would not take the aircraft out of service due to
another news helicopter being unavailable. It was decided to do the 100-hour in a manner
that would allow the aircraft to be put back in service within 10 minutes if operations
needed it. Upon reviewing the Work Order and Aircraft Status Record, several inspection
items were not completed, but on the status record were entered as completed. The work
order form was lacking 'Inspector' signatures, the 'Instruction for Continued Airworthiness
Inspections' were not signed off, and the Engine 100-hour and 750-hour inspection items
were not all completed. The log entry stated all inspections were done. The Engine
manufacturer's inspection requires a 100-hour Engine Health Inspection. This was not
completed and not signed-off on the inspection form. The aircraft was returned to service
without a complete inspection in accordance with the manufacture's recommendations.
The aircraft is operated under Part 135 and a log statement requires the aircraft to be
maintained In Accordance With (IAW) FAR Part 91.409.F.3.; the manufacturer's
recommended inspection program. This was not accomplished. The Repair Station
procedures for completing a Work Order and a Return to Service (RTS) log entry were not
followed. Consequences: aircraft placed back in service with overdue inspection items.
Callback: 1
Reporter stated one of the engines of a twin engine prop aircraft had plowed into one of
the two news helicopters on the ramp, resulting in his company's AS-350 Eurocopter's
being contracted for use as a dual purpose news gathering helicopter. Five Technicians had
been assigned to perform a portion of the 100-Hour Inspection in order to accommodate
the on-call demand, whenever the AS-350 was to be needed.
Reporter stated he had reviewed the Work Order and Aircraft Status Record the following
day as a Quality Assurance (QA) Lead Technician for the 100-Hour and 750-Hour
Inspections and noticed the incomplete paperwork, inspections not completed but signed-
off, incorrect log entries and the Repair Station procedures for completing a Work Order
and a Return to Service (RTS) log entry were not followed. He notified the Director of
Maintenance (DOM) about the release of their AS-350 Eurocopter with required
maintenance and inspections not completed, but response from his DOM was not
supportive of his concerns.
Synopsis
A Quality Assurance (QA) Lead Technician reports about one of their AS-350 Eurocopter's
that was placed back in service with overdue Airframe and Powerplant 100-Hour and 700-
Hour inspection items not completed. His company operations had contracted with a news
gathering organization to provide an AS-350 on short notice. He notified his Director of
Maintenance (DOM) about the non-compliance, but the response was not very supportive
of his concerns.
ACN: 1274075 (39 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Night
Aircraft
Reference : X
Component : 1
Aircraft Component : Indicating and Warning - Air Conditioning and Press.
Component : 2
Aircraft Component : Air Conditioning and Pressurizaton Probes & Sensors
Person
Reference : 1
Location In Aircraft : General Seating Area
Human Factors : Other / Unknown
Events
When Detected.Other
Assessments
Narrative: 1
I was assigned four airplanes: A, B, C, D and a crew consisting of nine people, plenty to
accomplish the work required for that night. I was working under the direction of Lead
Mechanic X, he wanted to address a specific item in Aircraft D that a previous Lead wasn't
comfortable performing. He [Lead Mechanic X] wanted to get people trained in performing
the Job Card, as he requested four specific people of his choice to perform the job, at
which I added two more people very proficient; all other aircraft maintenance was done
without incident. However, Aircraft D had some difficulties, we didn't have the right
equipment and no parts to replace the part if it failed, (Altitude Pressure switch).
Management assumed we had the parts and equipment to finish the job. We removed the
Pressure switch and started to test, [Altitude] Pressure switch failed, then we moved to
the test of the EPR and found out the equipment was registering a leak which we couldn't
find the source. The Supervisor determined the technicians weren't operating the
equipment correctly and ordered us to put everything back and he would cancel the job
cards, which he did. Then we ran the engine and found an EICAS message that won't [go]
away. Also, the Fuel Governor was leaking at a rate of 16 drops per minute. Supervisor
contacted Technical support and advised us that message wasn't a big deal, it eventually
would go away. I didn't feel comfortable stopping the test in the middle of the work and
putting all that we took apart back without finding out if the Pressure switch was ok, or if
we had an EPR leak, or if the EICAS message and fuel leak was related to we [us]
disturbing the system. We should have finished the test and found out either the system
was operating satisfactorily, or if not, what corrective action we needed.
Synopsis
An Aircraft Maintenance Technician (AMT) reports not feeling comfortable with an order
from their Maintenance Supervisor to stop all testing and reassemble all the items they
had taken apart after an Altitude Pressure switch had failed and an EPR leak was
discovered on a B757-300 aircraft. The supervisor canceled the Job Cards and noted the
technicians involved were not operating equipment correctly. Replacement for a failed
Altitude Pressure switch was not available.
ACN: 1273178 (40 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : None
Component : 1
Aircraft Component : APU
Component : 2
Aircraft Component : Oil Tank
Component : 3
Person
Reference : 1
Events
Assessments
Narrative: 1
On day-shift, around noon, I was assigned oil service on this aircraft with an [Aircraft
Maintenance Manual (AMM) Chapter] 12-79-01 [for servicing]. Per the [task] card, I
[made] 'Not Applicable' (NA'd) the APU [Task card] steps, as there was no message on
EICAS [to service]. I was not assigned an ETOPS check, nor was the aircraft within in a
three-hour ETOPS window at that time.
My assignment was not part of an ETOPS check (at airport ZZZ, we are assigned to service
every wide-body within one hour of arrival, regardless of destination) and I checked the
EICAS page, there was no APU OIL QTY message. I also noticed the aircraft was listed as
Out of Service (OTS) in our web based system. Later in the day, I observed a crew
working the same plane on an ETOPS departure, and no one had physically checked the
APU sight-glass. We suddenly realized this was a gotcha, and mechanics were assigned to
complete the APU sight-glass on a second 12-79-01 [Servicing card]. Had this
conversation not occurred, all agreed this aircraft would have departed out of compliance
with the ETOPS requirements.
[Recommend to] examine the specific items/ETOPS cards and resolve the possibility of the
APU NOT being physically checked and how to avoid non-compliances and/or FAA Letter of
Investigation (LOI). The NA is simply too easily missed.
Synopsis
A Line Aircraft Maintenance Technician (AMT) reports how a standard task card procedure
to check APU oils on their wide bodied aircraft within one hour of arrival by using the
EICAS page to determine if oil servicing was necessary, did not satisfy the requirement to
visually check the APU oil sight-glass for ETOPS flights. The B767-300 was originally
scheduled Out of Service (OTS), but later had an ETOPS flight scheduled.
ACN: 1272208 (41 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Dusk
Aircraft
Reference : X
Make Model Name : MD-82
Mission : Passenger
Component
Aircraft Component : Communication Systems
Person
Reference : 1
Events
Anomaly.Ground Event / Encounter : Other / Unknown
Assessments
Narrative: 1
Ramp was closed due to weather. The ramp tower at ZZZ called us and wanted to know
what the delay was. I told the Agent, the ramp is closed due to weather. About 10 minutes
later the ramp was open, but hand signals only. We could not do a manual [engine] start
without communicating with both the [flight] crew and the Mechanic on the engine without
a headset. The Lead Mechanic in charge did not want to send at least three people for a
Manual start; instead [we] only had two people. When you're getting hand signals from
the [flight] crew you can't see the Aircraft Maintenance Technician (AMT) on the engine to
signal [a] Start, Stop or Abort. And he, the AMT on the engine, can't see anyone in the
front of the aircraft getting signals from the FLT crew; and the flight crew has no idea on
what hand signals to use also, because there is no set of guidelines for this. [Contributors
were] a lack of safety concerns for employees and the aircraft.
Having a system in place and a policy on doing a Manual start with and without a headset
to communicate with the flight deck and the AMT manually starting the engine. If you're
using hand signals, how many people should we use and where are they positioned at and
can you even use hand signals to do a Manual start? Also, how to address an emergency
during a manual start with just hand signals. Then put this in a training bulletin.
Synopsis
A Line Aircraft Maintenance Technician (AMT) describes his frustration and safety concerns
surrounding a manual engine start procedure on the ramp with limited personnel and
having to use hand signals without a standard set of guidelines for everyone to follow.
Headsets could not be connected to the MD-82 aircraft due to weather conditions.
ACN: 1272205 (42 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : Jet Ranger All Series Undifferentiated or Other Model
Component : 1
Aircraft Component : Powerplant Fuel Control Unit
Manufacturer : Allison
Component : 2
Aircraft Component : Engine Indications
Manufacturer : Allison
Component : 3
Aircraft Component : Aircraft Logbook(s)
Person
Reference : 1
Events
Assessments
Primary Problem : Aircraft
Narrative: 1
June 2015, late afternoon; the pilot called me (approximately 80 miles from base) and
advised he had a 'FADEC Degraded' light illuminate in-flight. I asked him to power up the
aircraft and tell me if there was still a FADEC light. He said there was. I then asked him to
move the throttle to idle. He did and told me that the FADEC light went out. Knowing what
I know of the FADEC system, I knew that this indicated there were no current faults in the
system. I then asked him to do a ground run and call me back when he was done. He
called me back and advised that the run-up was fine and that there were no FADEC lights.
I asked him to power up the aircraft one more time to double-check that there were no
more FADEC lights. He did this and there were no lights. At this point I was not sure what
I could do to the aircraft so I advised him to fly it home. This has been an ongoing
intermittent problem since May 2015. We have replaced nearly every component in the
whole system. An Avionics Technician spent a couple days going through wiring and was
unable to find anything wrong. After speaking with my supervisor, (actually a Maintenance
Manager), over the incident, he informed me I should have not allowed the aircraft to fly
since I had not visually inspected it in accordance with a maintenance manual. He is
probably right, I wasn't sure what to look at that I hadn't already. This has been a
repeating problem that has been unable to be duplicated in the hangar. The FADEC
Manufacturer Technician Representative has been contacted many times & we have
followed all his advice. The aircraft would usually be in service for up to 10 days and fly 6
or 7 hours without any trouble. In my opinion, this intermittent problem has moved way
beyond the scope of a Field Base Mechanic & the aircraft should have been flown to a
Service Center where major disassembly or re-wiring can occur.
The bottom line is that I probably should have driven up to the aircraft, looked at it, and
made the proper logbook entries (even if the discrepancy could not be duplicated) before I
allowed the pilot to fly it home.
Callback: 1
Reporter stated the 'FADEC Degraded' light means the FADEC System was still controlling
the Rolls Royce-250 Engine, but had lost some of its functionality. The problem with trying
to troubleshoot and isolate the cause for the light illuminating was, the fault only occurs
every ten to twelve hours; and only in flight. The FADEC Manufacturer's Technical
Representative continued to believe the intermittent fault was caused by a wire chafing
somewhere.
Reporter stated his company finally sent the helicopter to a Service Center and the FADEC
Representative had a large wire bundle harness removed. A Technician laid the removed
wire bundle down on a table, inspected each wire and found two wires that had chafed
through a small area of wire insulation that had been contacting each other, but not
consistently. The wire bundle was replaced and so far, no other faults have occurred.
Synopsis
An Aircraft Maintenance Technician (AMT) was informed by a company pilot that one of
their Bell BHT-407 helicopters had a 'FADEC Degraded' light illuminate in flight. The
intermittent fault would occur every ten to twelve hours and had been an on-going
problem for months that could not be duplicated in the hangar.
ACN: 1272196 (43 of 50)
Time / Day
Date : 201506
Place
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Oxygen System/Pax
Person
Reference : 1
Location In Aircraft : General Seating Area
Events
When Detected.Other
Assessments
Narrative: 1
While working an Engineering Repair Authorization EC/EA and AD 2012-11-09, Step 2-B1
appears to have the mechanic inspect the existing cable, install the mask and insert
[Release] Cable pin into the striker pin of the cylinder if no damage was found. There was
a misunderstanding by the [maintenance] crew of Step 2 of AD 2012-11-09, since the
mechanic had to install a new cable, which is not addressed in AD 2012-11-09. As a result,
the Cable assembly and oxygen masks were incorrectly installed on a B777-200 Aircraft
during reactivation of the Oxygen System.
Additional reference should include an Illustrated Parts Catalog (IPC) 35-21-01-40b (item
C) for a better understanding of [Release] Cable routing. Also add a [maintenance] step to
install any missing cable to [passenger O2] box, including hardware, into the Engineering
Kit for AD 2012-11-09 and better training.
Synopsis
An Aircraft Maintenance Technician (AMT) recommends an additional reference be added
to Airworthiness Directive (AD) 2012-11-09 to include Illustrated Parts Catalog (IPC) 35-
21-01-40b, (item C). The IPC would provide a better understanding of the Passenger O2
mask box release cable routing. Misunderstanding of Step 2 of the AD resulted in an
incorrect installation of the release cable and O2 masks on a B777-200 aircraft.
ACN: 1271618 (44 of 50)
Time / Day
Date : 201506
Place
Aircraft
Reference : X
Component : 1
Aircraft Component : Weather Radar
Component : 2
Aircraft Component : Throttle/Power Level
Component : 3
Person
Reference : 1
Events
Assessments
Narrative: 1
Found weather radar 'On' and running in the hangar. Per reference [Aircraft Maintenance
Manual (AMM)] 34-43-00-040 Procedure it states, do not move the thrust lever. The
movement of the thrust lever can cause automatic operation of the Predictive Windshear
System. This can cause injury to persons and damage to equipment in the area of the
nose radome.
We need documentation to protect workers from this health hazard. Pulling Radar [Circuit
Breaker C/B] should be required before maintenance is performed. Most are not aware of
this hazard.
Synopsis
An Aircraft Maintenance Technician (AMT) reports finding a B737 weather radar unit 'On'
and running in the hangar during aircraft maintenance. Technician noted the need for
documentation to protect workers from the health hazards of radar operations should also
include pulling the Radar Circuit Breaker (C/B) before maintenance is performed.
ACN: 1270807 (45 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft : 1
Reference : X
Aircraft Operator : Government
Make Model Name : Large Transport
Aircraft : 2
Reference : Y
Aircraft Operator : Government
Make Model Name : Medium Transport
Component : 1
Aircraft Component : Pitot-Static System
Component : 2
Aircraft Component : Nose Gear Door
Manufacturer : Lockheed
Person
Reference : 1
Events
Assessments
Narrative: 1
I have a [Maintenance] Manager, Manager X, who continually attempts to cover up
discrepancies with the aircraft we have at ZZZ Flight Facility. Before I left for a [special
assignment], I wrote a discrepancy which downed [one of our engine turboprop] aircraft,
that had both nose landing gear doors out of rig. While I was [away], I was told that the
issue was resolved and that the door system was re-rigged. Upon my return I was walking
by the aircraft and noticed that it was still out of rig, I then approached Manager X about it
and questioned him. He asked me if we could not write the discrepancy up in the
[Maintenance Tracking Computer System]; and to fix it when we were working on a
different discrepancy. I refused to do that. I wrote it up in the [Maintenance Tracking
System]. Manager X was visually upset at me for this. He then confronted me and told me
I was wrong to write it up. I showed Manager X in the Maintenance Manual in which it
gives him instruction on how to properly perform the maintenance; he said he followed the
instructions as they were written. I asked him a few key points to the rigging and
explained to him why it was wrong. He said he could see my point but he still did not want
to go back to the [Agency] and tell them that he had done it incorrectly because it would
make him look bad. I told him that I could fix it correctly and that we need to do it right.
He agreed and then I re-rigged the doors.
Another instance Manager X had pressured me to perform a modification to an aircraft
system we have. One of our [aircraft] was in ZZZ2, I was sent out to install an additional
pitot probe, I had sent out the tools and required parts to perform the modification, I had
a drawing to follow that our Engineer had developed and approved. The Scientist whose
instrument it was, asked for me to make a major change to it. I informed the scientist that
I would have to get him in contact with our engineers to make the proper installation
drawing for me to follow and it would have to pass analysis. I also called Manager X and
filled him in on the matter. Manager X instructed me to have the scientist make pen and
ink changes on the drawing and to just do it. I informed him that I was not comfortable
making changes to a drawing without approval or an analysis done to it. After arguing with
me and trying to convince me that it would be OK and that my Airframe/Powerplant (A/P)
license would not be on the line, he finally gave up.
I have numerous cases about Manager Xs misjudgments and creating a work environment
where he wants to cut corners. I have listed a few and will give one more example.
I was in ZZZZ for another assignment this year and we had an issue with our [for engine
turboprop] aircraft. Aircraft Maintenance Technician and myself, troubleshot the
discrepancy: (#4 engine would not start). We discovered the engine to have two bad
ignitor leads. The solution was easily apparent, replace both ignitor leads, the old ones
were clearly unusable, one was arcing through the shielding and the other was broken in
half at the ignitor. I called Manager X to notify him that we would require new ignitor leads
to continue our science missions. He then tried to convince me to just use one ignitor lead,
off of another engine that was on the airplane. That would have had two engines with one
[good] ignitor lead each. The Exciter Box which supplies ignition power to the engine,
would have more than likely arced onto the closest possible item it could have to expel its
energy. A likely and close item [for that arc] could have been a fuel heater strainer and
could have resulted in a catastrophic disaster. I once again had to tell him that I was
uncomfortable with that type of maintenance. We installed the correct parts and were able
to continue our science missions safely.
These are a few examples of his managerial decisions that affect us and the safety of our
customers. I submit these to you worrying about what he has confronted other mechanics
with; has he convinced them to perform unsafe maintenance?
Callback: 1
Reporter stated that he and his Technician work partner were recently fired after notifying
the same Manager about several other aircraft discrepancies that required maintenance
prior to departure. Ironically, he (Reporter) noted he had helped the Manager get the
Maintenance Manager position.
Synopsis
An Aircraft Maintenance Technician (AMT) reports about his Maintenance Manager who
continually attempts to cover up discrepancies with the aircraft they have at their Flight
Facility. Technician also includes examples of the same Manager applying pressure to
perform maintenance or modifications to their aircraft, not in compliance with their
Practices and Procedures Manuals.
ACN: 1270752 (46 of 50)
Time / Day
Date : 201301
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : No Aircraft
Component : 1
Manufacturer : Rolls Royce
Component : 2
Manufacturer : Rolls Royce
Person
Reference : 1
Events
Assessments
Narrative: 1
Since [a few years ago], I have used on occasion a company issued LED Black light,
Inspecting Rolls Royce engine components and have been recently informed that No
Engineering Variance was issued for the use of these Lights.
Synopsis
An Aircraft Maintenance Inspector reports using LED Ultraviolet type lights for Fluorescent
Penetrant Inspection (FPI) of Rolls Royce Engine parts for more than two years, believing
an Engineering Variance had been issued to allow the use of the LED lights.
ACN: 1270457 (47 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Component
Aircraft Component : Pilot Seat
Person
Reference : 1
Events
Assessments
Narrative: 1
Company B757-200 aircraft. Captain seat track lock assembly faulty. Potential exists for a
pilot to loose control and wreck an airplane on approach when the seat shifts
unexpectedly. [I am] requesting a directive requiring increased scruntiny of this critical
mechanism on B757/B767 fleets. This is an unrecognized safety critical issue. I replaced
the seat assembly June 2015. A Routine Inspection Task card for the seat assembly is in
use and I suspect this is not enough to prevent future accidents. In this example, the
Captain found the problem and made a log entry.
Callback: 1
Reporter stated many of the B757s and pilot seats are 25 to 30 years old. He doesn't know
when, or if a seat overhaul is required, but he believes the segmented checks on their
B757s only require a yearly inspection for seat operation and condition. He found both
tension springs broken under the Captain's seat for the Track Lock Control lever. The lock
lever overcomes the spring tension in order to release the pin that locks the seat in the
seat tracks. The springs were not a line replaceable item. With both springs broken, the
Track Lock Control lever did not have a positive tension to secure the seat's latching pin in
the seat's floor tracks. As a result, he could easily make the seat slide forward or aft
merely by shifting his weight in the seat.
Reporter believes the minimal maintenance checks for flight crew seats are not adequate
to maintain seat serviceability. That's why reporter was requesting a fleet wide campaign
to check flight crew seats on B757/B767s. Reporter wants to be clear that the seat design
is not the issue, just the limited maintenance checks of the seats, which do not seem to be
adequate.
Synopsis
A Line Aircraft Maintenance Technician (AMT) reports about an unrecognized critical safety
issue that exists for pilots to lose control of B757/B767 aircraft on approach, if the pilot
seat shifts unexpectedly due to broken Seat Track Lock Control assemblies. Technician
suspects the routine seat inspection task card is not sufficient to maintain adequate
serviceability of crew seats.
ACN: 1270323 (48 of 50)
Time / Day
Date : 201506
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Function.Flight Crew : Pilot Flying
Events
Result.Flight Crew : Returned To Gate
Assessments
Narrative: 1
The crew from [aircraft X] called over the aircraft radio enroute to ZZZ1. They said that
his Blue Overhead Fuel Valve light was illuminated. I asked if the engine was still running,
they said yes. I asked if the engine was operating within normal parameters, they said
yes. I asked if there was any engine fluctuation, they said no. I told him that it appeared
to be an indication issue. The crew agreed and continued the flight to ZZZ1.
I completed a Turnover Report in the Maintenance Control turnover log that the Overhead
Blue Engine valve light was illuminated. Upon landing in ZZZ1, the [flight] crew created a
discrepancy that it was the Spar Valve light that had illuminated in flight.
I had believed that the crew was discussing that it was the Engine Valve light that was
illuminating. Because of this belief, I had even discussed with the crew there would be a
possibility MEL'ing valve in ZZZ1. I turned this information over to the on-coming
Maintenance Control shift. The aircraft Engine Valve was MEL'd in ZZZ1 by the on-coming
shift. The aircraft flew to ZZZ2 where company Maintenance determined that the MEL may
have been incorrectly applied. ZZZ2 Maintenance corrected the Spar valve problem and
cleared the Engine Valve MEL. ZZZ2 Maintenance noted that the discrepancy and the
resolution did not balance.
My belief had been that the crew had been seeing an Engine Valve fault. I turned this
information over to the on-coming shift. The crew wrote that they had a Spar Valve fault.
The on-coming shift used my turnover report to apply an MEL that may have not been
correct. ZZZ2 Maintenance replaced the Spar valve and cleared the Engine valve MEL.
Ensure that discrepancies and resolutions balance.
Narrative: 2
Aircraft had pilot report (P/R) inbound to ZZZ1 for # 2 Eng Spar valve Blue light illum in
flight. I contacted ZZZ1 Maintenance & told Tech we would MEL the light. Tech read me
the log page but I did not hear him say it was the Spar valve the crew had written up. I
instructed the tech to accomplish the procedures for the MEL I wanted to apply 73-10.
Tech accomplished them. There was a communication problem with which c/b needed to
be pulled & collared and the location of it. The MEL for the "Eng. valve light" # 73-10" was
completed. Initially I had the tech collar the incorrect breaker which was rectified later.
After the acft arrived in ZZZ2 the techs called ZZZ Maintenance Control and informed
them of the error.
At start of shift, received [Turnover] tie-in that "Eng. valve light illum bright." My first
thought was a Cowl Anti-Ice light was on. My co-worker told me to look again at the tie-in
and I read that it was a Eng. valve lt. I pulled up the MEL for that light (not uncommon for
it to occur) and contacted the tech in ZZZ1. After the acft landed the tech read the P/R to
me. I missed the tech telling me it was the Spar valve & not the Eng valve. I proceeded to
have the tech MEL the Eng valve as stated above. We had a discussion while filling out the
book about circuit breaker (C/B) location. At that time I had the tech collar the wrong
breaker at my direction. This error was discovered later & amended to the correct c/b for
that MEL.
While Tech in ZZZ1 was accomplishing the MEL I was answering calls from other techs &
helping with a window heat in ZZZ3 & in ZZZ4 with a piece of debris in a panel in front of
the elevator. Techs in ZZZ2 trouble shot/s & repaired the system originally written up.
Reversed the MEL procedures & removed the MEL. I didn't look at the log page picture the
Tech sent from ZZZ1 till the next day on my way to work. I make it a priority to look at
them as soon as possible. Maintenance Controller. Evening [shift]. Workplace interruptions
during task.
Narrative: 3
Technician Y was assigned to do company B737-800 aircraft [inbound] flight [into ZZZ1].
Upon arrival of aircraft at gate, there was in inbound write-up for # 2 Engine valve light
illuminated. I, Technician X, was then called upon by Technician Y to perfom MEL 73-10
Maintenance Procedure for # 2 Engine, [because] he was not qualified to do engine runup.
After completing MEL 73-10 procedure with no faults, I then turned it over to Technician Y
who was in direct contact with ZZZ Maintenance Controller X to close out the resolution
description block with MEL procedures applied. After aircraft was pushed back from gate, I
was called on our Maintenance cell [phone], that the aircraft was returning to gate for no
'engine start'. Upon arrival to gate, I found that the wrong Circuit Breaker (C/B) was
pulled and collared. It was determined after the fact that information and guidance by ZZZ
Maintenance Control that the MEL to pull and collar the C/B was for another MEL
procedure. I then proceeded to correct the issue and pulled and collared the proper C/B
per the MEL 73-10.
Narrative: 4
Maintenance performed MEL on Fuel Spar issue, MEL improper applied. Maintenance
applied wrong procedure to Fuel Spar MEL, engine did not start.
Synopsis
Two Maintenance Controllers, an Aircraft Maintenance Technician (AMT) and a Captain
describe their involvement with a reported # 2 Engine Fuel Spar Valve Overhead Blue light
fault that was miscommunicated and deferred as an Engine Valve Blue fault light on a
B737-800 aircraft. A downline Maintenance Station noted that the original discrepancy and
the resolution did not match. Spar valve was replaced and Engine Valve MEL cleared.
ACN: 1270315 (49 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Dusk
Aircraft
Reference : X
Component
Aircraft Component : Main Gear Door
Person : 1
Reference : 1
Person : 2
Reference : 2
Function.Flight Crew : Pilot Not Flying
Experience.Flight Crew.Last 90 Days : 113
Experience.Flight Crew.Type : 5300
Events
Anomaly.Ground Event / Encounter : FOD
Detector.Person : Air Traffic Control
Assessments
Narrative: 1
I was assigned to work the Center Axle Inspection on a B777. I used a long wooden 2"x4"
as a tool to align the truck with the inner cylinder on the LH Main Landing Gear (MLG).
When we achieved alignment, at approximately late morning, I placed the tool on the
outer lip of the main landing gear wheel well door. We then proceeded to reassemble the
LH main landing gear center axle. Later that evening I was performing Brake Operational
checks in the cockpit with the Inspector. When the checks were complete, the mechanic
on the ground began to service the Center system hydraulic fluid. I was observing the
quantity in the cockpit and asked the mechanic on the ground to close the landing gear
doors so we would have an accurate quantity reading. When we finished the fluid service, I
went to the ground, completed the Job Card and began to clear away the remaining
tooling and equipment so the aircraft could be taken out of the hangar. Apparently, the
tool was still on the door when the door was closed and fell out of the wheel well when the
aircraft went on a flight the next day.
Aircraft/Cabin potential damage caused By FOD.
[Recommendations]:
1) The tool should not have been placed on the door.
2) The door should have been cleared better before it was closed.
3) The tool was an old, dirty 2x4, brown and black in color. A brightly painted board would
be easier to see.
4) Only two mechanics were assigned to finish this job which included down jacking the
aircraft, removing the jacks, servicing the landing gear struts and transitioning the aircraft
from Air Mode to Ground Mode.
Narrative: 2
Just after takeoff Tower said another aircraft reported that something fell from our aircraft.
We asked them to let us know what they found. No negative indications from aircraft
instrumentation. No negative flight control effects. We asked Flight attendants if they
noticed abnormal noise or sights - nothing. It was reported that airport ops found a 2x4 on
the runway. We consulted Maintenance, determined nothing amiss and continued to
destination.
Synopsis
An Aircraft Maintenance Technician (AMT) reports placing a 2" x 4" board against the outer
lip of the Left Main Landing Gear (MLG) door after completing a Center Axle alignment on
a B777 aircraft. MLG door was closed later, but the 2X4 fell out of the wheel well after
takeoff also told from the perspective of the Captain of the flight. Distractions, workload
and limited staffing were contributors.
ACN: 1269736 (50 of 50)
Time / Day
Date : 201506
Place
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : Bell Helicopter Textron Undifferentiated or Other Model
Component : 1
Aircraft Component : Fuel Tank
Manufacturer : Bell Helicopters
Component : 2
Aircraft Component : Fuel Booster Pump
Manufacturer : Bell
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Narrative: 1
1/4" Drive 7/16" Shallow Socket unaccounted for during FWD Fuel Cell replacement FAA
Alert Service Bulletin (ASB) compliance. Socket used to Torque (TQ) Fuel transfer lines
inside fuel bladders. Last believed used to TQ Boost Pump and Transfer Pump housing.
Discovered missing after Aircraft was fueled for Return to Service. Barrels for waste fuel
were full from initial defuel. Aircraft was scheduled for training flights early evening.
Thorough search of the facility and aircraft was initiated. Decision was made to enter a
discrepancy of missing socket. Entries included inspection of critical areas that would effect
safety of flight, ie. Engine Air Intake, Intake Plenum, Engine Deck, Transmission Deck,
Flight Control Vertical Tunnel, Flight Controls and Rotating Members. Trash cans that were
used throughout duration of ASB compliance were emptied that afternoon. The existing
trash cans were sorted through. Given more time, arrangements to empty the waste fuel
barrels and defuel the aircraft to inspect Fuel Bladders would have been the next course of
action. Training Flight crew was notified of situation and actions taken. Decision was made
to accept the aircraft for service. Lack of assertiveness.
[Recommendations:]
Travel box with tool control. Tool verification at the end of each working day. Trash
collection should be done after completion of work.
Synopsis
An Aircraft Maintenance Technician (AMT) reports about the efforts made to locate a 1/4"
inch drive, 7/16" inch shallow socket that was unaccounted for after a Forward (FWD) Fuel
Cell replacement on a Bell BHT-407 helicopter. Inspections of critical areas that would
effect safety of flight were accomplished; socket not found. Fuel tanks were not drained.
Training Flight crew accepted aircraft for service.

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ASRS Database Report Set

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

Update Number ....................................................28.0

Date of Update .....................................................January 29, 2016

Number of Records in Report Set ........................50

Number of New Records in Report Set ...............50

Ames Research Center

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

Linda J. Connell, Director

ACN: 1307353 (2 of 50)

ACN: 1305894 (3 of 50)

ACN: 1304978 (4 of 50)

ACN: 1301789 (5 of 50)

ACN: 1300292 (6 of 50)

ACN: 1299377 (7 of 50)

ACN: 1299325 (8 of 50)

ACN: 1299093 (9 of 50)

ACN: 1297551 (10 of 50)

ACN: 1295814 (11 of 50)

ACN: 1295357 (12 of 50)

ACN: 1294332 (13 of 50)

ACN: 1294072 (14 of 50)

ACN: 1293413 (15 of 50)

ACN: 1292485 (16 of 50)

ACN: 1291853 (17 of 50)

ACN: 1291474 (18 of 50)

ACN: 1290978 (19 of 50)

ACN: 1289759 (20 of 50)

ACN: 1289753 (21 of 50)

ACN: 1289750 (22 of 50)

ACN: 1288221 (23 of 50)

ACN: 1287823 (24 of 50)

ACN: 1282992 (25 of 50)

ACN: 1282664 (26 of 50)

ACN: 1281886 (27 of 50)

ACN: 1280088 (28 of 50)

ACN: 1279377 (29 of 50)

ACN: 1278743 (30 of 50)

ACN: 1278430 (31 of 50)

ACN: 1278065 (32 of 50)

ACN: 1277063 (34 of 50)

ACN: 1275197 (35 of 50)

ACN: 1274898 (36 of 50)

ACN: 1274892 (37 of 50)

ACN: 1274216 (38 of 50)

ACN: 1274075 (39 of 50)

ACN: 1273178 (40 of 50)

ACN: 1272208 (41 of 50)

ACN: 1272205 (42 of 50)

ACN: 1272196 (43 of 50)

ACN: 1271618 (44 of 50)

ACN: 1270807 (45 of 50)

ACN: 1270752 (46 of 50)

ACN: 1270457 (47 of 50)

ACN: 1270323 (48 of 50)

ACN: 1270315 (49 of 50)

My lead proceeded to instruct one of our unlicensed mechanics to repair it by placing

My lead annotated on the paperwork the following:

Shorthanded, distracted with interior items trying to save boarding time.

[Company] General Procedure Manual (GPM) XX-XX-2 Responsibility and Authority.

[Company] General Procedure Manual (GPM) XX-XX-3. Responsibility for Maintenance

Federal Air Regulations: