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A DC9-30 on a maintenance ferry diverted due to a gradual loss of cabin pressure caused by an improperly closed aft plug door.
| Attributes | |
| ACN | 551395 |
| Time | |
| Date | 200206 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | DC-9 30 |
| Operating Under FAR Part | Part 121 |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician observation : passenger |
| Qualification | technician : powerplant technician : fcc technician : airframe |
| Experience | maintenance lead technician : 1.75 maintenance technician : 10 |
| ASRS Report | 551395 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician observation : passenger |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | flight crew : diverted to another airport |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : weather performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Weather Flight Crew Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
We were on a road trip to ZZZ for a left temperature low light. After finding the sense line loose to the anticipator, we did a pneumatic check in the morning with the air crew running the aircraft for us. After completing the check, the test equipment was removed and the aircraft was returned to normal operations. The plug door was installed. We did a walkaround and the air crew got ready for the ferry flight. I signed off the logbook and gave it to the captain and told him we were ready to go. We left ZZZ and had an uneventful flight. After about 1 hour, we lost cabin pressure and descended to 10000 ft. We could then hear ails from the plug door. We went back and inspected and found the bottom of the door had popped out and air was escaping. The aircraft was later changed to go to ZZZ2 maintenance base. In ZZZ2, the plug door was inspected and reinstalled per maintenance manual. They did a cabin pressure check and released the aircraft for service.
Original NASA ASRS Text
Title: A DC9-30 ON A MAINT FERRY DIVERTED DUE TO A GRADUAL LOSS OF CABIN PRESSURE CAUSED BY AN IMPROPERLY CLOSED AFT PLUG DOOR.
Narrative: WE WERE ON A ROAD TRIP TO ZZZ FOR A L TEMP LOW LIGHT. AFTER FINDING THE SENSE LINE LOOSE TO THE ANTICIPATOR, WE DID A PNEUMATIC CHK IN THE MORNING WITH THE AIR CREW RUNNING THE ACFT FOR US. AFTER COMPLETING THE CHK, THE TEST EQUIP WAS REMOVED AND THE ACFT WAS RETURNED TO NORMAL OPS. THE PLUG DOOR WAS INSTALLED. WE DID A WALKAROUND AND THE AIR CREW GOT READY FOR THE FERRY FLT. I SIGNED OFF THE LOGBOOK AND GAVE IT TO THE CAPT AND TOLD HIM WE WERE READY TO GO. WE LEFT ZZZ AND HAD AN UNEVENTFUL FLT. AFTER ABOUT 1 HR, WE LOST CABIN PRESSURE AND DSNDED TO 10000 FT. WE COULD THEN HEAR AILS FROM THE PLUG DOOR. WE WENT BACK AND INSPECTED AND FOUND THE BOTTOM OF THE DOOR HAD POPPED OUT AND AIR WAS ESCAPING. THE ACFT WAS LATER CHANGED TO GO TO ZZZ2 MAINT BASE. IN ZZZ2, THE PLUG DOOR WAS INSPECTED AND REINSTALLED PER MAINT MANUAL. THEY DID A CABIN PRESSURE CHK AND RELEASED THE ACFT FOR SVC.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.