A B737-300 AFTER TKOF DECLARED AN EMER AND DIVERTED WITH LOSS OF HYD PRESSURE AND QUANTITY DUE TO DAMAGED LINES CAUSED BY A UNSECURED DEPARTING WING PANEL.

Date: 2001-05 · Aircraft: B737-300 · Phase: ground

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-maintenance|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-other-unknown

Synopsis

A B737-300 AFTER TKOF DECLARED AN EMER AND DIVERTED WITH LOSS OF HYD PRESSURE AND QUANTITY DUE TO DAMAGED LINES CAUSED BY A UNSECURED DEPARTING WING PANEL.

Narrative

ON MAY/XA/01; AN ACR PLANNER HANDED ME A 'CD' [JOB CARD] #XXXXX; REPLACEMENT OF SPOILER AND BRAKE HYD LINES IN R AND L WINGS; THAT HAVING BEEN COMPLETED AND TURNED IN BY MECH AND ALL BLOCKS HAD BEEN STAMPED NEED THE LAST PAGE SIGNED OFF BY THE LEAD. A PAGE WAS ATTACHED FOR WORK CARRY-OVER AND TURNOVER. AS A RULE; WHEN THE MECH STAMPS OFF THE REGULAR BLOCKS ON THE 'CD' AS HAVING BEEN COMPLETED; THIS INCORPORATES ALL TURNOVER INFO ON ANY ATTACHED PAGES. BELIEVING ALL WORK HAD BEEN ACCOMPLISHED; I SIGNED OFF THE LAST PAGE TO COMPLETE THE PACKAGE BEFORE THE PLANNER PUT AWAY THE PAPERWORK. APPARENTLY AN ITEM IN THE PAGE WAS OVERLOOKED AND A TOP R WING PANEL WAS NOT SECURED. THE PANEL AND ATTACHED HYD LINES CAME OFF INFLT; DIRECTLY AFTER TKOF; CAUSING LOSS OF HYDS AND A RETURN TO GATE. REMOVING THE PANEL IS 1 STEP TO BE STAMPED ON THE 'CD' PAPERWORK; BUT THERE IS NO BLOCK TO SPECIFICALLY INSTALL THE PANEL. INSPECTION WAS OVERLOOKED IN THE PAGE. THE 'CD' SHOULD BE MODIFIED TO INCLUDE INSTALLATION OF ALL REMOVED PANELS AND EQUIP. BECAUSE THIS JOB GOES FROM SHIFT TO SHIFT OFTEN BEFORE COMPLETION CONTRIBUTES TO ITEMS BEING OVERLOOKED ON TURNOVERS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE COMPANY SYS ENGINEER AND JOB CARD WRITER HAVE CORRECTED AND REVISED THE JOB CARDS INVOLVED IN THIS INCIDENT. THE RPTR SAID JOB TURNOVER PROCS ARE UNDER REVIEW AND SOME CHANGES WILL BE MADE.

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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.