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deck on our ferry flight. The cart struck the center pedestal
preventing damage to any flight instruments.
I, the First Officer, failed to properly secure the aft galley as
per our flight handbook. During preparation to start the
flight, I did assure that the forward galley was secured. For
some reason, I didn’t think to check the aft galley. We don’t
[do] ferry flights very often so it is easy to overlook cabin
security during a ferry flight. I am now sure I will always
check cabin security on my future ferry flights.
An almost identical situation was experienced by a B737-
400 crew on a recent repositioning flight.
…Because we were the only people on board, we kept the
cockpit door open. Captain…crossed the threshold of Runway
33 on speed, on course and touched down at the proper
touchdown point. Without warning, at about 100 knots there
was a loud bang and hissing noise in the cockpit. We
continued to stop the airplane on the runway. As the airplane
came to a stop we realized the aft center galley cart had
traveled through the center aisle of the aircraft, crashing into
the center console of the airplane. Several pop cans had been
dislodged and were at our feet. Some had burst.
None of the cans hit the forward instrument panel…
It’s easy to envision even worse damage occurring to
cockpit instrumentation and occupants, including
jamming of flight controls by loose cans and injury to pilots.
Securing the cabin during preflight is the best defense
against such incidents.
ETOPS Sign-offs
A maintenance incident reported to ASRS carries a
reminder that sign-off requirements for ETOPS (Extended
Range Operations) repairs are restrictive – a point that
can easily be forgotten.
I am an A&P mechanic for a major international
airline. Another mechanic and I were assigned two tasks
on a Boeing 767-300ER. Per our company’s policies and
procedures manual, only those people designated as
“ETOPS Qualified” (EQ) may sign off tasks or
discrepancies on most systems on the aircraft. A non-EQ
mechanic may work under the supervision of an EQ
mechanic and the EQ mechanic may sign off the nonqualified
mechanic’s work. I am not EQ, while the other
mechanic is. We had pretty much wrapped up the first task
and…I began the second task, which was to replace a
bearing tube assembly on an engine…The other mechanic
joined me not long after I started to remove and replace the
tube, and in fact assisted me with the installation. We
completed the replacement per the maintenance manual
and leak-checked the line, which was found to be OK for
service. Later in the shift the other mechanic made all the
required logbook entries for the items we had worked,
except for the entry for the tube replacement. He handed the
logbook to me so I could enter and clear the item, which I
did.
A few days later, I received a memo and copy of the log page
from my foreman indicating…I may not have been in
compliance with our policies and procedures regarding
ETOPS only tasks.... As it turns out, any maintenance
done on the engines is considered an ETOPS item, so I was
most definitely not in compliance by making the entry for
the repair in the logbook. The maintenance performed was
OK, as I was being supervised by an EQ mechanic. The
sign-off was the problem…
On non-ETOPS aircraft it is common to pass around the
logbook for each mechanic to sign off his work. This has
become more habit than we thought, [even though] we have
all received ETOPS awareness training. Some solutions
we have implemented are to post a “read and sign” [notice]
reminding everyone of the restrictive nature of ETOPS
maintenance. The foreman also intends to meet with the
leads and remind them to be more aware of whom they are
assigning work to on an ETOPS airplane.
ASRS Recently Issued Alerts On…
Non-standard hold lines at a Midwest airport
Inflight activation of a G-IV stall barrier system
Fokker-100 loss of rudder control on short final
Uncoordinated Mode C testing by maintenance at a FBO
An airport’s ground holding procedures for landing aircraft
June 2001 Report Intake
Air Carrier / Air Taxi Pilots 2232
General Aviation Pilots 729
Controllers 81
Cabin/Mechanics/Military/Other 193
TOTAL 3235
Number 264 August 2001
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
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