A319
Maintenance Powerplant; Maintenance Airframe
Communication Breakdown; Confusion; Distraction; Situational Awareness; Time Pressure; Training / Qualification; Workload
Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy
General Maintenance Action
Aircraft; Chart Or Publication; Company Policy; Environment - Non Weather Related; Human Factors; Procedure
January 2012; I; Mechanic X and three other mechanics were assigned to work an Airbus A319 aircraft with IAE V2500 engines. The four of us went to the gate to bring our assigned Aircraft into the hangar because of the inclement weather; of snow mixed with freezing rain. After getting the aircraft in the hangar; we divided up the Work Cards and began our work. I had the Job Card for the 'V2500 Variable Stator Vane (VSV) Actuation Force Check and Lube'. This would be my first time working this job card; and none of my three co-workers had done this job before; nor did they know what the job entails.A week earlier I was working another aircraft with the same job card. At that time my co-worker and I were told to defer the job card by Supervisor X because the needed tool kit was not available; because it was being refurbished due to being dropped and damaged. He also told my co-worker; Mechanic Y and I that the tool kit needed to perform the job is not listed on the job card. Knowing that this may still be the case; I went to see if the tool kit was available for use. Reading my job card I ordered from the Parts/Tool Room the necessary parts and tools. Knowing the required tool kit used to accomplish this job was not listed on the job card; I asked the Tool Room attendants if they knew of the tool kit I was looking for; they told me they knew of no kit for that specific job.I asked my Supervisor Mr. Y; about the tool kit. He informed me that he just received an e-mail the previous day stating the tool kit was returned to the Hangar Tool Room. Supervisor Y went into the Tool Room for the tool kit and brought out two; Dial Type; 50-Inch Pound torque wrenches. Thinking that I now had the proper tools to accomplish the task; I began to setup for the job. Mechanic Z; assigned to the A319 aircraft with me; started to assist me in the job. Following the job card after opening the fan cowls; we arrived at Step-3; which was to pin the Hydraulic Control Unit (HCU) deactivating the Thrust Reversers. The HCU is located atop the engine under the pylon. Mechanic Z had gone to get a pump; so that we could open the Thrust Reverser ducts. While he was doing that; I accomplished Step-3 which told me to pin the HCU. Mechanic Z came back with the pump and we proceeded to open the thrust reverser ducts. Shortly after this my Supervisor Y asked if I would stay [over] for the 1st shift; [for] De-ice Overtime and I agreed. Mechanic Z and I continued with the job and soon came to realize that I had the wrong tools for the job. I informed my Lead Mechanic about the problem and also told him that I had never done this job before; and that I did not have the proper tools and that the Maintenance Diagrams in the Job Card were illegible and vague as to where we take the torque measurements. I read the job card further and it states that if the torque value is over 350-inch pounds; to notify Engineering. My Lead Mechanic reviewed the job card and went to look at the engine himself. We determined that the torque wrenches were not only too small; but of the wrong style; and that a Torque Adaptor or Crows Foot would also be required for the job; again; neither is listed on the job card as required tooling.I told my Lead that the previous week I was assigned the same job and that the Supervisor X told me to defer the job due to the tool kit being missing. So we called Supervisor X and asked if he heard about the tool kit being returned for use. He told us that it was still out. Supervisor X had provided a tool number to our Lead and I; for a torque wrench that could be used for the job and also told us we needed a 7/16 inch Crows Foot. I checked out the torque wrench and asked for the required Crows Foot or Torque Adapter; neither of which was available in the Tool Room. I asked several mechanics if they had a Crows Foot or Torque Adaptor for me to borrow; and no one had one. I went to tell my Lead that I could not locate the proper tools for the job. At that time; Supervisor Y told me to defer the job; stating that we were working higher priority duties. He then told us to close-up the engine so we could be used for de-icing. Mechanic Z and I started to do as told by Supervisor Y. The first thing we did was to replace the bolt and nut as in Step-(8) of the work card and had Inspector X witness the new bolt and nut being installed and torqued. We then proceeded to Step-7; closing of the Thrust Reverser and Fan Cowl Doors'. At Step 7(e); we are instructed in the work card to keep the Thrust Reverser Unserviceable and HCU Deactivated. While closing the engine; Supervisor Y reminded me that the de-icing overtime will be starting soon. Mechanic Z and I closed the fan cowls; cleaned the work area; and started our paperwork; forgetting that the HCU was deactivated; I did not remove the pin. The following day; Supervisor X asked to speak with me. We went into another Supervisor's office; and he asked me if I had worked the A319 aircraft the previous day and I replied yes. Then he asked who was assigned with me on that aircraft and I told him two other mechanics and Mechanic Z. Then he asked who it was that worked the engine. I told him that I did and that Mechanic Z was helping me. He then informed me that the aircraft flew and upon landing had a thrust reverser failure. After landing Maintenance opened the fan cowls and found the HCU pinned and deactivated. Thrust reverser failure message during landing. Number One thrust reverser did not deploy. Contributing causes: 1). No experience performing this job. 2). Not familiar with the IAE V2500 engine. 3). The proper tools not being listed on the job card. 4). The proper tools not available to accomplish the task. 5). The tool kit used not listed on the job card and not available. 6). Job card diagrams not legible or clear. 7). Wrong tool information provided by Supervisor 8). Not having taken lunch break; that could have helped to me to relax and think more clearly about the job 9). Too much work load on work crew due to inclement weather demands. 10). Work being scheduled when tools are not available. 11). Letting pressure from Supervisor about de-ice duties keep me from paying better attention to the job. 12). Supervisor Y telling me to defer the job halfway through the work card; so that I will be available for de-icing duties. Suggest: 1). Have a witness and challenge [procedure] during installation and removal of pins and safety devices. 2). Change work card so that Step-7 does not say 'Closing of the thrust reversers and fan cowl doors'. Instead make it three separate steps requiring an OK to close from Inspection. 3). Log book entry. 4). In job cards that can be deferred; [add] a section that must be stamped; ensuring that everything is safe and secure for flight.
A Mechanic describes in great detail the effort he went through trying to accomplish an IAE V2500 Engine Variable Stator Vane (VSV) Actuation Force Check and Lube Jobcard on #1 engine; only to be told to close-up the engine cowls and defer the job. The lock-out pin was not removed from the Hydraulic Control Unit (HCU) preventing reverser deployment on the next flight.