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A B777-200 was pushed back off a gate, but halted by maintenance request. Borescope accomplished, but no signoff for plug installation and safety.
| Attributes | |
| ACN | 633885 |
| Time | |
| Date | 200410 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | Marginal |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : pushback ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Experience | flight time last 90 days : 125 flight time total : 8000 flight time type : 750 |
| ASRS Report | 633885 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure non adherence : company policies |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
After being cleared for pushback by ground and releasing the brakes, the tug driver told us that a maintenance manager had stopped the push. We queried maintenance manager on the radio and they did not know why. We later found out that the aircraft had been borescoped (#2 engine) and that the signoffs for the work had not been completed. Maintenance opened the cowl to ensure that the plug had been safetied, and it had. My problem with this situation was that we were improperly dispatched from a maintenance standpoint, and that if someone in maintenance had not 'caught' this, the plug had not in fact been installed, we could have had a catastrophic engine failure due to a maintenance oversight.
Original NASA ASRS Text
Title: A B777-200 WAS PUSHED BACK OFF A GATE, BUT HALTED BY MAINT REQUEST. BORESCOPE ACCOMPLISHED, BUT NO SIGNOFF FOR PLUG INSTALLATION AND SAFETY.
Narrative: AFTER BEING CLRED FOR PUSHBACK BY GND AND RELEASING THE BRAKES, THE TUG DRIVER TOLD US THAT A MAINT MGR HAD STOPPED THE PUSH. WE QUERIED MAINT MGR ON THE RADIO AND THEY DID NOT KNOW WHY. WE LATER FOUND OUT THAT THE ACFT HAD BEEN BORESCOPED (#2 ENG) AND THAT THE SIGNOFFS FOR THE WORK HAD NOT BEEN COMPLETED. MAINT OPENED THE COWL TO ENSURE THAT THE PLUG HAD BEEN SAFETIED, AND IT HAD. MY PROB WITH THIS SIT WAS THAT WE WERE IMPROPERLY DISPATCHED FROM A MAINT STANDPOINT, AND THAT IF SOMEONE IN MAINT HAD NOT 'CAUGHT' THIS, THE PLUG HAD NOT IN FACT BEEN INSTALLED, WE COULD HAVE HAD A CATASTROPHIC ENG FAILURE DUE TO A MAINT OVERSIGHT.
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.