A B737-300 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH THE R MAIN LNDG GEAR BRAKES INOP.
Synopsis
A B737-300 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH THE R MAIN LNDG GEAR BRAKES INOP.
Narrative
I INSPECTED AN INSTALLATION OF A R-HAND MAIN LNDG GEAR TRUNNION BEARING AND LINK. THE DAY WAS JUL/XA/99 IN THE EVENING. THE MECH SIGNED OFF ON THE WORK AND I STAMPED OFF ON THE INSPECTION OF THE WORK ON A ROUTINE WORK CARD; ALTHOUGH THE BRAKE HYD LINES WERE NOT CONNECTED. THE CONNECTION OF THE LINES WERE NOTED ON A FORM ATTACHED TO A NON ROUTINE CARD BEING WORKED WITH THE ROUTINE CARD. LATER I FOUND OUT THAT THE FORM WHICH THE BRAKE LINE WORK WAS NOTED ON WAS LOST. NO DOCUMENTATION FOR THE BRAKE WORK EXISTED AFTER THE LOSS OF THE PAPERWORK. THE RESULT WAS THE PLANE WAS RELEASED FOR SVC WITHOUT THE HYD BRAKE LINES CONNECTED FOR THE R-HAND MAIN GEAR. THEY WERE LATER FOUND AND CONNECTED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE LOSS OF AN ATTACHMENT CARD TO A ROUTINE LNDG GEAR JOB CARD WAS THE CAUSE OF THE AIRPLANE BEING RELEASED WITH NO R MAIN LNDG GEAR BRAKES. THE RPTR SAID THE PAPERWORK NOW IN PLACE WORKS AS FOLLOWS: A ROUTINE LNDG GEAR JOB CARD IS ASSIGNED TO 1 OR MORE TECHNICIANS TO REMOVE THE LNDG GEAR AND ITS CTL NUMBER IS ENTERED ON A WORK CTL CARD AND IN THE COMPUTER. THE RPTR STATED AS THE TECHNICIANS BEGIN TO REMOVE THE LNDG GEAR AND DISCONNECT LINKAGE AND HYD LINES THEY USE AN 'ATTACHMENT' CARD WITH REF TO THE LNDG GEAR ROUTINE JOB CARD AND IS ACTUALLY ATTACHED TO THE JOB CARD LISTING BITS AND PIECES REMOVED FROM THE LNDG GEAR AND HYD LINES CAPPED. THE RPTR SAID THIS 'ATTACHMENT' CARD IS NOT NUMBERED NOR IS IT ENTERED ON THE WORK CTL CARD OR COMPUTER. THE RPTR STATED IN THIS INCIDENT THE ATTACHMENT CARD WAS LOST AND ALL WRITE-UPS ON THE CARD WERE LOST AND NO ONE IN THE 5 SHIFTS WORKING ON THE GEAR KNEW AN ATTACHMENT CARD EXISTED. THE RPTR SAID THE COMPANY PAPERWORK IS ARCHAIC AND WILL HAVE TO BE UPDATED TO PREVENT ANOTHER SERIOUS INCIDENT. THE RPTR SAID THE ACFT WAS RELEASED AND A TEST FLT WAS ACCOMPLISHED WITH A PLT RPT OF 'SOFT' R BRAKES AND #3 BRAKE WAS REPLACED. THE RPTR STATED AT THIS POINT THE ERROR SHOULD HAVE BEEN CAUGHT SINCE THE BRAKE REPLACEMENT REQUIRES HYD PRESSURE TO ALLOW BRAKE BLEEDING PER THE MAINT MANUAL. THE RPTR STATED THE ACFT WENT INTO REVENUE SVC FOR 2 DAYS BEFORE THE R MAIN GEAR BRAKES WERE DISCOVERED INOP. THE RPTR SAID THE FAA HAS CONDUCTED AN INTERVIEW FOR THEIR INVESTIGATION.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.