'It Wasn't Recorded on a Job Card'

Air Safety Week, Sept 13, 2004

How the purge door came to be left open

ASW: Did anybody inspect the work on the purge door before signing off on the job card?

BA: Nobody inspected the purge door because there was no job card, as the purge door is not explicitly required by the aircraft maintenance manual [AMM] to be removed to access and purge the tank on a 777, as it is for a 747.

ASW: Was the closing of the purge door somehow overlooked during shift turnover?

BA: The removal of the panel was not recorded. There were many issues around shifts and different teams working on the tank. Ultimately, these are contributory factors in how the door was left open, but only because it wasn't recorded on a job card. Familiarity with the aircraft and area was an issue due to the inaccuracies of the AMM. Actions are being taken to address some of these issues.

ASW: Was the individual who removed the purge door interviewed?

BA: All staff involved in working on the center tank were interviewed.

ASW: Wouldn't the unsecured purge door have been detected during preflight walk around inspections?

BA: The location of the [purge] door and the bag are not visible from the ground with the undercarriage door shut. There had been no requirement to open the gear doors in the time since the aircraft had been in maintenance. Even with the gear door open, [the purge door] is difficult to see from the ground.

ASW: What changes have been put in place to prevent a recurrence?

BA: Immediate actions include shift briefings and other communications on the importance of recording all work done, corrections to the maintenance manuals by Boeing and additional work cards raised by British Airways. Longer term recommendations include improved processes for managing engineering queries, changes to center fuel tank working practices and a review of the control of panels removed in maintenance.

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