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above the E&E door opening.
Preventive measures: Do not rush to fi nish job no matter
what stress is put on you. Not getting enough sleep (fatigue).
Pressure from management and leads, poor lighting inside
the E&E, and working outside in the early morning.
Lack of Knowledge
A B757-200 technician interpreted the stamped numbers
on the APU (Auxiliary Power Unit) and engine fi re bottle
squibs as expiration dates. The main “dirty dozen” factor that
contributed:
Lack of Knowledge: Lack of training for the task
􀂄 …Aircraft was in phase check…I was tasked with checking
the APU #1 and #2 engine fi re bottle squibs for expiration
on their 10-year life cycle. I was not given OJT [On the Job
Training] before performing the task. I interpreted parts of
the stamped numbers on the shoulder of the squibs to be
d a t e s . This aircraft went to heavy check, and it was
found that these squibs were near expired
or
expired…After receiving OJT in
reference to the…occurrence, I realized
the expiration dates were etched and not
stamped on the shoulder of the squibs. I
suggested, and my company will modify,
their phase task cards to require a date
and serial number block be added to the
task cards.
Lack of Communication
A common “dirty dozen” factor played a role in an incident
involving a B757-200 emergency slide pack installation:
Lack of Communication: Failure to verify tasks
􀂄 Myself and another technician were given the task to
replace the left wing overwing emergency slide pack. We
accomplished the task and signed the proper documents and
logbook. When the aircraft went into a heavy maintenance
check, it was discovered that the slide deployment lanyard
was not connected to the attach point, rendering the slide
pack useless. Myself and the other technician are new to the
station and only worked together a few times. I believe there
was miscommunication between ourselves in carrying out
the Maintenance Manual steps in the installation of the slide.
Also working in a dark environment (nighttime) we didn’t
detect the error. Double-checking the work performed is also
required in aircraft maintenance.
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Number 346 October 2008
October, the eighth month in the old Roman
calendar (“octo” means eight), is the official month for
National Popcorn Poppin’, Canadian Thanksgiving,
Columbus Day, and Halloween, to mention just a few
of the events celebrated in this month. This harbinger of
autumn, pumpkin festivals, and trick-or-treating also seems
an appropriate month in which to share Unexpected Events
reported to the ASRS. If these events have anything in
common, it’s that the unexpected should be anticipated in
aviation activities.
“It Soon Got Very Dark and Quiet”
Shortly after landing, a B777 had to apply heavy braking
to avoid overtaking a slower aircraft during taxi to the gate.
After this conflict, the Boeing Captain stated to the First
Officer that they should “probably shut one down” [to avoid
repeated braking for the slower aircraft]. The First Officer’s
report tells what happened next:
n …I looked over and noticed he was guarding the left fuel
control so I shut the right engine down. To our dismay, it
soon got very dark and quiet and we realized we had both
shut an engine down. The Captain braked the aircraft to a
stop. I cranked the APU, remained seated, notified Tower
we would be holding for a few minutes and waited forever
for the minute to pass and enjoy the resumption of electrical
power. I then started both engines. We resumed taxi to
the gate. The outcome was a 4-minute delay in taxiing to
the gate at the end of an otherwise very normal flight. No
doubt stressful for the crew and passengers. From a human
factors point of view…I feel that fatigue and jet lag played
an important role on this evening…flipping one’s body clock
by 12 hours in a 24-hour period has its challenges. It is still
a 2-pilot operation in the dark on the backside of the body
clock….
The Captain’s report of this same incident added that there
was “too much verbalization” in the cockpit and “not enough
commands.”
“A Cigarette Boat Was Upon Us”
An instructor pilot and student aboard a float-equipped
PA18 became airborne prematurely when they encountered
unexpected high-speed boat traffic on a river.
n We had just departed the sea plane base and back ‘water’
　
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