kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration 31610 04-aug-05 F-HSEX 31560 1-Aug-05 PH-BQI 31557 27-Jul-05 PZ-TCM 31552 03-aug-05 PH-BQB 31550 02-aug-05 none 31538 30-jul-05 OO-TNB Issued by : Issued : SPL/QA September 08, 2005. Description Management Archive (CARMA). De Non-Conformity heeft betrekking op het onvoldoende vertalen door de afdeling Engineering van in AD notes gestelde eisen op MRI’s, en taakkaarten, waardoor in de productie beoordelingsfouten zijn ontstaan bij het catagoriseren van uitgesteld werk. Ondergetekende heeft de reparaties aan de betreffende wastecontainer acces doors op 03 aug 2005 fysiek gecontroleerd op het vliegtuig en daarbij geen afwijkingen meer geconstateerd. Voor het verlengen van het BVL van deze registratie heeft het bovenstaande derhalve geen gevolgen. Found transparent tape on the LH-side alternate static port before starting leakcheck of the pitot/static system. found at pfc and daily chk from brake assy pos 4 the fwd brake wear ind gone and aft brake wear ind hanging loose,fwd was already on ddl,when both are missing brake must be replaced No action description was made on AML M869 concerning reverser deactivation on engine 2. As a consequence no reference was made to the Aircraft Maintenance Manual. In Manilla the lh Taxi light was found cracked. This was en route deferred. In Amsterdam the taxi light was found Covered with cardboard and taped with high speed tape. The cardboard was almost completely burned away, and the mounting flange/bracket was scorched. No CB's were pulled. Altough the light was cracked, the fillament was still working. It seems that since approximately 25 july there are no occurences reported. At least none have been printed or received thru mail at both Duty Maintenance Managers (WB+NB) desks This applicable for all a/c types ! After stabilised approach during landing flare, a/c subjected to windshear, one main wheel touched down before the otherand damage was caused to left main Status TIR Feedback Action by: OPEN 0 HF-WB OPEN 0 USO-WB WILL INVESTIGATE WITH DECO TEAM CE WILL BE CONTACTED TO SEE IF THIS IS A NORMAL SITUATION FOR A RELATIVELY NEW BRAKE MONITO RING 0 Ground engineer will be contacted and issue will be made part of CT HF-LM OPEN TIR 05-163 will be investigated by HF-LM HF-LM CLOSED 0 0 CLOSED 0 Dat de occurrence mail niet doorkomt kan kloppen, dat is een afspraak die is voortgekomen uit een wens van MCC zelf. Reden is dat MCC de meldingen alleen op de printers wil krijgen. Dat de printers het niet doen is gek. Daar hebben we een spoedstoring voor aangemeld OPERATIONAL INCIDENT. NO ACTION ON KLM 145. OPERATOR INFORMED. MSO page 16 of 132 0 kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration Description Status TIR zonder dat ze gemerkt zijn met de critical task stempel deze kaarten stonden ook niet op de criticaltask tally sheet Feedback Action by: denken dat er wat geslipt is bij de PSG maar gelukkig heeft deze oplettende gwk dit herkend als een critical task en de juiste aktie genomen, chapeau! Blijken trouwens taakkaarten te zijn van EMDP, EDP en supply filters verwisselingen en dus echte critical tasks! 30831 10-jul-05 PH-BFD Possible birdstrike during landing. Thorough visual inspection of aircraft , no sign of damaged. Found in ams during pfi lh inb aft flap nose area cracked.[see m844] ,caused by birdstrike in IAH. OPEN 0 Birdstrike is een operationeel incident. Wat ik me wel afvraag is of men IAH ook de flaps heeft laten zakken om een inspectie uit te voeren. Met flaps "up" is het niet mogelijk deze schade te zien. 0 30827 10-jul-05 ALL 0 0 0 0 30825 10-jul-05 all 0 0 0 0 30819 10-jul-05 PH-BPB the pay of bonuses in areas where safety is an issue is a bad thing. this can result in incorrect made decisions safetywise. It still appears to me that there are a lot of people who are not actually responsible for the release to service of an aircraft, are trying to influence the decision(s) that ground engineers make in the dispatch. Some people are not sensitive for this kind of pressure but I can understand that others may break down easily. Given the fact that safety and legal documents are the things we have to use as wel as the fact that all other departments only have an advising function, I would strongly advice to tell those people not to apply this kind of practises. Some day this will end in an disaster and we all know that the poeple who have pushed us engineers, will deny any involvements. During OPC emergency lights acc Bow task CE83261, noticed on rh side fuselage near aft flaps, emergency light very weak. CLOSED 0 Een paar maanden geleden hebben wij ook een occ. gehad waar verkeerde lampjes in de cockpit gemonteerd zaten bij de window heat lights, deze kan daaraan toegevoegd worden. Volgens het MEL 33-14-00 zou zelfs de exterior emergency lighting u/s 0 Issued by : Issued : SPL/QA September 08, 2005. page 30 of 132 kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration 28327 22-Apr-05 PH-BFK 28326 22-apr-05 PH-BXH 28319 22-apr-05 PH-KCB and PH-KCE 28311 22-apr-05 EC-IYI 28310 22-apr-05 PH-KCF 28264 20-Apr-05 PH-BQA 28252 20-Apr-05 PH-BDN Issued by : Issued : SPL/QA September 08, 2005. Description incorrect. lower redbar same problem. this all resultated in stick shaker warning at fl300. speed indication on f/o side was correct. Catering at ams reported damage on wing to body fairing rh side below door 22. Found AD 2001-11-07 overdue on Motor-operated shutoff valve PN EM 56-20 (Vendor Circle Seal). Subject AD is effective from july 16, 2001 with compliance-time of 3 years, ending july 16, 2004. During an occasional check on two MD11 aircraft on Schiphol Centrum, I did the following findings on D151 type tourist class seats on MD11 aircraft: On several occasions the bolt/nut connection of the Hydrolok to the seatback was not according CMM 25-90-21 of the specific seats. In many occasions there where wrong nuts and/or wrong bolts fitted, Also washers where missing. In total I found more than 10 nuts missing. In one occasion de bolt dropped from the hydrolok (PH-KCE). I have made contact with line maintenance on F pier, line maintenance fitted a new bolt and nut. These aircraft had both D-checks in China. Wrong ipc used to find partnumber and so the wrong partnumber is ordered and installed. Only one(1)partnumber was ordered instaed of Two(2)different partnumbers,left and right is different. DEFECT: DURING ENG START LEVEL 1 ALERT HYD PUMP TST FAIL. During flt pax observed rh wing upper surface movements , crew also inspected and reported same, on advice MCC return back to SPL Ref. AML M619, dd. 110305: Due to leakage of toilet flush water in aft cargo compt. removed cargo loading Status TIR Feedback Action by: CLOSED 0 DAMAGE CAUSED ON OUTSTATION. Dit is een van de eerste meldingen van schade door belading, heeft verder geen onveilige situatie opgeleverd ( verf beschadigd). Voorlopig deze occurrence in de trend volgen. Anders nog enige awareness eraan geven door uitgave Flash 0 OPEN TIR 05-082 UNDER INVESTIGATION QA QA OPEN 0 IT SEEMS WE NEED TO PUT MORE ENERGY IN MANAGING OUTSOURCING ACTIVITIES HF-WB OPEN 0 MORE ENERGY SHOULD BE PUT ON MANAGING THIRD PARTY WORK HF-NB OPEN 0 0 HF-LM OPEN TIR 05-083 QA OPEN TIR 05-080 UNDER INVESTIGATION QA. UP TO NOW NO INDICATION OF WHAT REALLY HAPPENED UNDER INVESTIGATION QA page 77 of 132 QA kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration 27035 8-Mar-05 PH-BDW 27031 8-Mar-05 PH-BFU 27030 8-Mar-05 PH-BDW 27019 7-Mar-05 PH-BDW 27018 8-Mar-05 PH-BXL 26959 06-mar-05 PH-BDO 26929 3-Mar-05 PH-KCB 26928 4-Mar-05 26927 4-Mar-05 Issued by : Issued : Status TIR Feedback Action by: CLOSED TIR 05-035 TIR REPORTED FOR STATISTICS 0 OPEN 0 MSO MONITO RING 0 MONITO RING 0 Komt veelvuldig voor, probleem zal worden voorgelegd aan Engineering om een structurele oplossing te zoeken. ALSO MANY THANKS FOR OCCURRENCE, WELL OBSERVED. WILL BE MADE PART OF CT VERY GOOD OCCURRENCE REPORT. WELL OBSERVED. WILL BE MADE PART OF CT. CLOSED 0 ADMINISTRATIVE PROBLEM. 0 CLOSED 0 0 MONITO RING 0 PH-BFA De-icing required according ground engineer. No information from flight crew on the ATL action side about start time, fluid-type used or mix-ratio. Open entry is not released on outbound station, at SPL 2 days later the entry is closed. DD was not entered in MSF so no telex went to stations. Occurrence is op verzoek van QA gemeld door de EUR-DMM, waarom dus niet op de dag dat het gebeurde vragen we ons af. ATL entries: M584/585/588/589/590/591. QA heeft Grd. Services gevraagd het schaderapport op te sturen. Het voorval is veroorzaakt door gebrekkige communicatie tussen cockpitcrew en truckdriver. CAPTAIN SHOULD HAVE REFERRED TO DE-ICING IN ATL OPEN 0 PH-BFA LIGHTS ; FOUND FLOOR PROX LT AT SEAT 28ABC - CLOSED TIR 05-029 SPL/QA September 08, 2005. Description release system as alternate extension) found wrong type of lightbulb installed in the flightdek emergency dome light. the partnumber installed was a 1308 (28 v)iso 1317 (6v) Fire Prot/ equipm : occurence report : main deck cargo smoke separation shield lh inbd decompression panel found in open position . APU air check valve is touching angle assy above the check valve. 05-M5003/ 817552/ 028457 LH Wing, Krueger Flap 2 leading edge cavity area. Pneumatic pipe line for water system pressurisation which is clamped to wing anti ice duct is touching slat hydraulic line just outboard of wing landing light. Also check nut is loose where pipe line passes through rib installation going inboard. 11-M5013/ 817301/ 028457 Anti skid box removed from BXL to serve BXK. Removed unit 680294 with x-label 1357986. Apperntly unit not used for BXK and got lost at schiphol centrum. Found a unit installed in BXL without log of maintenance action. Traced part/serie number of unit and found installed on BXC. A/C rolled forward after pushback track disconnected and hit truck with nose gear. De cockpit crew is zo te zien waarschijnlijk vergeten de slip in te vullen WILL BE ADDED TO TREND DATA FOR 0 0 HF-LM HF-LM page 105 of 132 0 kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration 26429 Enkele dagen geleden ? 26428 15-feb-05 PH-BFC 26427 15-feb-05 PH-BTA 26416 15-feb-05 PH-MCF 26400 15-feb-05 PH-BFN 26391 8-Feb-05 PH-BZG 26333 13-Feb-05 PH-BFF 26302 11-Feb-05 PH-KCG Issued by : Issued : SPL/QA September 08, 2005. Description oil leakage if engine was started. Na in-taxie-en bij gate werden motoren uitgezet, maar bleef beacon lt branden. Personeel dat vliegtuig afhandelt bleef op afstand, blokken werden niet geplaatst. Iemand in de gate met geel hesje gebaarde de cockpit crew dat de blokken er lagen, waarop de brakes werden gereleased. Vliegtuig rolde daarop 4 mtr naar voren. GWK die wilde inpluggen moest wegspringen. INCIDENT Tijdens intaxie-en op F4 was opstelvak voor vliegtuig niet vrij van grond-equipment. Nacelle motor 1 raakte container of bagage-kar (waren niet bij ongeluk aanwezig). Persoon die visual docking systeem bediende heeft noodstop bedient om erger te voorkomen. floorfittings from girdbar at lh fwd entry door where incorrectly installed. (180 degrees turned) found during wheel change #15 one brake disc all pins missing and disc broken in two. FLIGHT COMPARTMENT FWD OF LDG CONTROL HANDLE MODULE P2-3 (BS 270/RBL 7.23/WL 332.14): LDG QAUDRANT FASTENER NUT (REF.IPC 32-31-6601 ITEM 120) AT BEGINING OF THREAD (OF MOUNT BOLT) - SUSPECT NOT TO BE FASTENED BEFORED.d 26-JAN-2005 AFT cargo compartment lining was not repaired, but cargo was still carried for three fligths, this is not in accordance with the MEL. NWA report was filed. Smoke Separation Shield Main deck Cargo most Lh outbd decompression panel found in open position. PH-KCG staat met klachten in buitenland, onze PH-KCE moet spare main-battery & battery-charger meenemen. Er is echter maar 1 battery besteld terwijl de batteries als paar verwisseld moeten worden. De 2e accu komt uit H11, maar er is geen runner die hem brengt. Of wij hem willen brengen wordt door LMO-er gevraagd. In H11 bij magazijn blijkt dat er geen ADR-formulier (vervoer gevaarlijke stoffen) is, daarom neemt runner battery niet mee. Batterijen en charger naar vliegtuig, geen papieren aanwezig, batterijen mogen zo niet mee. We worden naar Status TIR Feedback Action by: OPEN 0 0 MSO OPEN 0 0 MSO OPEN TIR 05-023 0 HF-NB CLOSED TIR 05-021 INFORMED OPERATOR MARTINAIR 0 OPEN 0 uitzoeken HF-LM MONITO RING TIR 05-020 THE SUBJECT MEL WILL BE COVERED BY CT. WOO MONITO RING 0 MSO CLOSED 0 WOO; regelmatig voorkomend probleem, zullen naar structurele oplossing moeten zoeken. Het lijkt erop dat een niet hiervoor geautoriseerde medewerker iets probeert te versturen en daar niet de geeigende procedures volgt. Het antwoord is dan ook dat technici helemaal niets (zeker geen DG) moeten vervoeren buiten het technisch areaal en daarvoor de expedities of magazijnen moeten raadplegen. De DG WPI's van CS: 130010, TW130020, page 115 of 132 0 kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date 26017 2-Feb-05 Aircraft registration PH-BXG 25978 30-Jan-05 PH-BTG 25950 31-jan-05 PH-BXG 25945 30-jan-05 PH-BTA 25941 29-Jan-05 PH-BTH 25925 30-Jan-05 PH-CKC Issued by : Issued : SPL/QA September 08, 2005. Description After H-visit on 01-feb-2005, aircraft was transported outside H10. Noticed APU fire extinguisher has low press agent light illuminated. After troubleshooting found plug D48080P has internal continuity between contacts and therefore APU fire extinghuisher was discharged. Plug in very bad shape. Hil m660 29 jan 2005.RH runwayoff light cb popped.Replaced rto light on m672.Found wrong lamp installed 4554 iso 4551.Acc ipc l331,install pnr 4551. On m680 the engineer suggested the there was a wrong rto was installed and installed a new lamp. Both lamps where replaced on the same station mxp. After de-icing at OTP, crew performed full flight control checks after pushback. During check flaps failed to extend beyond 24 degrees. Initial trouble shooting showed failure in flap load relief circuit. During maintenance main rudder pcu was disconnected from rudder. The hydraulic shutoff valves in the tail compartment were in a position between the open and closed position. For maintenance safety, they should have been completely closed... Hydraulic pressure was, if flight control switches in flight compartment were placed in the "on" position, available for the main rudder PCU. This probably happened and resulted in a damaged rudder pcu and damage to the rh vertical beam of the vertical fin. No danger tags were placed in the flight compartment. The bolt which connects the main rudder pcu to the rudder was u/s and a new one was ordered aog. (job interrupt jc 08-M5010) Landing gear: found during inspection at lh main landing gear, upper drag strut mounted 180 degrees wrong. upper fuse pin mounted now from outboard to inboard. DEFECT: DURING CLIMB OUT AFTER +- 10MIN LOUD BANG FROM BEHIND COCKPIT. DELTA-P WAS 7.0 PSI. 2ND BANG AFTER 15 MIN DELTA-P 8.3. 3RD BANG AFTER 26 MIN DELTA-P 8.3 PSI. SOUNDS LIKE THERE IS SOME TENSION IN THE AIRCRAFT DURING CABIN - PRESSURE CONT OF M994: BUILT Status TIR Feedback Action by: 0 MONITO RING 0 SHORT CIRCUIT IN PLUG.PLUG WILL BE INVESTIGATED. MANY THANKS FOR OCCURRENCE REPORT. CLOSED 0 PLEASE CONSULT MANUALS FOR RIGHT P/N. 0 CLOSED 0 ISOLATED CASE. 0 MONITO RING 0 Hydraulic Shut off valves can be opened involuntarily. WE consider issue of an Aircraft Safety FLASH. HF-NB CLOSED 0 0 OPEN 0 180 GRADEN VERKEERD OM MONTEREN KAN. IS BIJ TOEVAL NA MAANDEN PAS ONTDEKT. FLIGHTCREW HEEFT EERSTE TWEE VOORVALLEN NIET IN BOEK GEZET! KIST HEEFT ER TWEE KEER MEE GEVLOGEN. MSO NEEMT CONTACT OP MET ENGINEERING. HF LM NEEMT CONTACT OP MET FLIGHT. MSO page 122 of 132 kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration 25923 30-Jan-05 PH-BFC 25922 30-Jan-05 PH-CKB 25917 29-Jan-05 PH-OFD 25915 28-jan-05 PH-BTA 25914 28-Jan-05 ph BFO 25910 28-Jan-05 ph-bfg 25865 27-Jan-05 EI-CUA Issued by : Issued : SPL/QA September 08, 2005. Description UP ALSO REPORTED BY CREW OF 9182 HKG-DXB ON 26TH JAN AND BY CREW OF 9168 SIN-DXB ON 30TH OF JAN. HERAM: Afgelopen week 3x meegemaakt dat equipment uit gereedschapsmagazijn VOC ontbreekt. 1) loodjestang om brandblusfles van nieuw zegel te voorzien was weg (missing) 2) push-pull unster om flightcontrol klacht te controleren acc. MAI was weg (missing) 3) loep om crack te inspecteren was weg (missing. During PFI today, found complete paperwork of H-check 27 jan 05 (BOW-AMS-CKB-27jan2005-1) in cockpit cabinet. Fuel was leaking out of the rh wing wingroot vent drain.Flame arrester valve was stuck open and a nock on the valve made it reseated and stopt the fuelleak. During rebuild of cockpit due to MO53-0351 found both EHSI's missing. Could not find any paperwork regarding the removal of both EHSI's. After check in COMPAS/CROCOS system found both units to be removed from aircraft on 31-dec-2004. Tijdens FA NFDE gevonden op densito meter van HST tevens uitgesteld werk van 21 juli 2004 met zelfde klacht en daarbij stond RA 495087 ingevoerd NRC 08M5001 M.a.w. kist vliegt al een half jaar met een NFDE en die lossen we niet op omdat er geen onderdelen besteld worden. Er was ooit beloofd dat dit gecoverd zou worden dat RA's wel op tijd geleverd en of besteld worden. Bij andere mijen is dit echt niet mogelijk Diverse AMM verwijzingen op de taak kaarten in de FC zijn niet terug tevinden in M-BOX. BV: operational check of: forward cargo container compartment acc amm 25-5300/575 ff par 76 and 77 post mo 25-2718b. Bij navraag bij CE moet er een light weight lowerdeck cargo handeling system-test uitgevoerd worden. Een operational check is niet het zelfde als een system test. Door dat de tekst niet klopt en de amm verwijzing niet te vinden is worden verkeerde testen uitgevoerd. According minutes of meeting 07 dec 2004 written by Mr. Status TIR Feedback Action by: OPEN 0 Hf-LM zal contact opnemen met VH . HF-LM CLOSED 0 Indidenteel. HF-LM CLOSED 0 DOORGEGEVEN AAN CITYHOPPER 0 CLOSED 0 PROCEDURE MBT KANNIBALISATIE IS NIET GOED GEVOLGD 0 OPEN 0 LIJKT OP EEN PROBLEEM MET WERKVOORBEREIDING; ER IS EEN WPI VOOR MONITOREN UITGESTELDE NON ROUTINE. KOMEN WE OP TERUG. HF-LM MONITO RING 0 M-BOX PROBLEEM. ZAL WORDEN OPGENOMEN MET ENGINEERING.SPL/CC3 ( AMP groep) heeft dit specifieke geval aangepast, rest van de M-BOX problemen is men doende om het in te plannen MSO MONITO 0 Een duidelijk voorbeeld van het niet goed 0 page 123 of 132 kem QUALITY ASSURANCE – SPL/QA SUMMARY OF REPORTED OCCURRENCES 2005 Number Date Aircraft registration 25835 25-Jan-05 N/A 25832 26-Jan-05 PH-BFW 25821 25-Jan-05 PH-BXK 25788 24-Jan-05 5Y-KQZ Issued by : Issued : SPL/QA September 08, 2005. Description Status X. At point 2 procedures annex A blue panorame has no regulation about double inspection items. At point 3 procedures annx B blue panorama allows KLM E&M to perform work according KLM procedures. This also means duplicate inspection as mentioned in KLM appendix c. According maintenance management &organization exposition(MMOE) of Blue Panorama part 2.23 control of critical task: at point 2.23.2 taks about additional inspection items(double inspect)witch is more than what KLM E&M has stated in there Appendix C for duplicate inspect. At blue panorama it also includes powerplant/landing gear and airframe structures(see MMOE 2.23.2 of Blue panorama) this problem is mention at the project supervisor Found in H14 bay 1 again 2 cylinders used for compressed gas filled with not " DRY NYTROGEN" but with AR/CO2. Only " DRY NYTROGEN" may used in the hangar. A/C TOOK OFF AT AMS WITH NO AIRSPEED AND ALT INDICATIONS ON CAPT SIDE (ADC-L). (T/O WAS NOT ABORTED??) AFTER SWITCHING CAPT SIDE TO ADC-C ALL IND NORMAL. IN ORD THEY FOUND PITOT / STATIC CONNECTORS NOT CONNECTED ON ADC-L. (ADC-L REPLACED ON M953 / 25JAN05) REMARK: IS IT ALLOWED TO MAKE A T/O UNDER THESE CONDITIONS?? Found during inspection at nose landing gear, lower torsion scissor hit by towbar less towing truck at lh side, mid part of torsion scissor 23-01-05 at d18. This aircraft was the spare aircraft used for PH_BXD which was hit by a bagage truck. Upon arrival it was noticed that on the left engine two "do not operate" tags were installed on the thrust reverser doors. Only the most lower ones were installed. When checking the Acceptable Defered Defect book no entry was made of a deactivated reverser neiter were the two control CB's pulled. When we asked the new crew they were aware of a deactivated reverser but this could not RING TIR Feedback Action by: voorbereiden en op de hoogte stellen van de P&P van een klant. CLOSED 0 TRANSFER NAAR ARBO. WOO CLOSED 0 HF onderzoek uitgevoerd.Info bij HF-LM op te vragen. HF-LM CLOSED 0 foto's zijn opgevraagd. Foto's zijn doorgestuurd naar Ground. 0 OPEN 0 Op buitenstation is niet goed gedeactiveerd en is ook het boordboek niet bijgewerkt..betrokken GWK heeft een zeer effectieve actie uitgevoerd via de Telex. Operator zal op de hoogte gebracht worden (via TQ) MSO page 124 of 132