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|
Attributes | |
ACN | 1322235 |
Time | |
Date | 201601 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Regional Jet 700 ER/LR (CRJ700) |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Flap Control (Trailing & Leading Edge) |
Person 1 | |
Function | Technician |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Maintenance Deviation - Procedural Published Material / Policy |
Narrative:
Mechanics a and B were assigned to a road trip for a flap failure EICAS message. Mechanic a was temporarily assigned rii. Maintenance control (mx ctl) believed that failure was caused by either a brake position sensing unit (bpsu) or spoiler/flap electronic control unit (sfecu). Mechanics a and B were also lowest two in seniority at time of assignment. When dropped off to aircraft (a/C) mechanics notified mx control that they had arrived. Asked mx ctl where they wanted T/south to begin with. Mx ctl stated to try swapping sfecu. The fault remained in maintenance diagnostic computer (mdc) flagging bpsu. Mechanics a and B then were directed towards bpsu. The panel for bpsu was removed. The lower cannon plug on bpsu was wrapped in F4 tape flagging the attention of both mechanics. Mechanic B then removed F4 tape to reveal several damaged shielding and improper sealing of cannon plug. Mechanic B then notified mx ctl of condition. Mx ctl stated to just splice the wire. Mechanic B told them that no supplies for splicing were brought for the trip.mx ctl stated that they would contact hangar for supplies. During the wait for more information mechanic B contacted hangar to ask about splicing materials. Hangar notified mechanic B that you cannot just splice into a bpsu wire bundle. When mx ctl contacted mechanic B with update mechanic notified mx ctl that hangar said a standard splice could not be performed. Mx ctl arranged for a service bulletin (sb) kit for proper splicing. Mx ctl notified mechanics around 3 am that they were arranging charter to fly parts in at 5 am. Charter did not arrive until 7am. Mechanic B asked about possible ferry of a/C to hangar. Mx ctl stated that a ferry permit was being attempted and to hold off on splicing wires until notice. At around 9 am mx ctl called stating that permit was denied and that only option now was cut wire bundle and splice.multiple times mechanic B asked if they were sure that they wanted this procedure done that once started the sb stated a 31 hr work time for a mechanic with experience on this system to perform task. They once again ensured that this was only option. Mx ctl was looking into finding a hangar to perform work. FBO denied access to hangar space. Mx ctl then suggested that mechanics get a couple tarps and throw them over the wing and borrow a salamander heater so that they could perform work. Mechanics thought this to be unsafe so they did not follow recommendation and continued to work in winds and low temperatures. Mechanic a then cut wires to start assembly of new wire bundle splice. During assembly procedure mechanics a & B realized that wire identifiers sent in the kit were not for the lower cannon plug but for upper cannon plug. Mechanics were concerned and called hangar for advice. It then became aware to the mechanics that the sb only had instructions for splicing upper cannon plug. It has now been around 24 hours that mechanics a and B have been on the clock. During this 24 hour period they have been through several mx controllers who did not have proper turn over. Mechanic B notified mx ctl that wire identifiers did not match up with lower cannon plug wire identifiers and wanted to know that if they could relabel wires with heat shrink printer that O/south maintenance provided. Mx ctl did not have an answer. During this time fatigue was really kicking in. Mechanics decided that they were exhausted and would like relief. Mx ctl then asked if there was any way they could quickly do splices to just limp that a/C to a mx base. Mechanic B then stated you do not understand this is a 31 hr task there is no quick way and noted that mx ctl was notified several times that task was a 31 hr job. Mx ctl then stated that a charter had been sent and that mechanics could either wait for charter to arrive and fly back with charter or choose a hotel. Mechanics decided on flying in charter back to base. During the wait for charter to arrive mechanics filled out paperwork for workperformed. When asked on how to sign off cutting the wire bundle mx ctl gave them a reo for lower cannon plug splice. Mechanics did not have copy of reo sent in the sb packet sent in supply charter. Lap top computer sent with mechanics also does not have access to sb or reos. Replacements arrived at 11pm and mechanics a and B provided turn over to mechanics C and D and proceeded to fly back to base.after landing mechanics a and B talked to supervisor about trip. Supervisor stated that he had recommended to mx ctl several times that waiting for weather to improve for a ferry would be best option that if they were to make mechanics work in conditions that they were setting the mechanics up for 100% failure due to FAA dirty dozen suggestion on human factors. He stated then that mx ctl said they could not do that. He also stated that when mechanic a was concerned over paperwork being improper for work performed that mx ctl stated that they did not have time to read over and not their job to read sb being sent to mechanics to perform. Mechanic a when returned was also informed that experienced avionic tech takes 8 hours alone to assemble bundle and had no business doing this task in the elements. Mechanic a rested and as he return to following night it became more aware that a possible error could easily have resulted due to conditions that occurred during road trip.events occurred because of mx ctl extreme lack of communication during shift turnover. Freezing weather with moderate winds was also a factor. Fatigue of mechanics. Lack of system knowledge. Lack of experience.
Original NASA ASRS Text
Title: Due to weather conditions and wrong parts sent; Maintenance was unable to make necessary repairs to the damaged wire harness.
Narrative: Mechanics A and B were assigned to a road trip for a Flap Failure EICAS message. Mechanic A was temporarily assigned RII. Maintenance Control (Mx Ctl) believed that failure was caused by either a Brake Position Sensing Unit (BPSU) or Spoiler/Flap Electronic Control Unit (SFECU). Mechanics A and B were also lowest two in seniority at time of assignment. When dropped off to Aircraft (A/C) mechanics notified MX CTL that they had arrived. Asked MX Ctl where they wanted T/S to begin with. Mx Ctl stated to try swapping SFECU. The fault remained in Maintenance Diagnostic Computer (MDC) flagging BPSU. Mechanics A and B then were directed towards BPSU. The panel for BPSU was removed. The lower cannon plug on BPSU was wrapped in F4 tape flagging the attention of both mechanics. Mechanic B then removed F4 tape to reveal several damaged shielding and improper sealing of cannon plug. Mechanic B then notified Mx Ctl of condition. Mx Ctl stated to just splice the wire. Mechanic B told them that no supplies for splicing were brought for the trip.Mx Ctl stated that they would contact hangar for supplies. During the wait for more information Mechanic B contacted hangar to ask about splicing materials. Hangar notified Mechanic B that you cannot just splice into a BPSU wire bundle. When MX Ctl contacted Mechanic B with update mechanic notified Mx Ctl that Hangar said a standard splice could not be performed. MX Ctl arranged for a Service Bulletin (SB) kit for proper splicing. MX Ctl notified mechanics around 3 AM that they were arranging charter to fly parts in at 5 AM. Charter did not arrive until 7am. Mechanic B asked about possible ferry of A/C to hangar. Mx Ctl stated that a ferry permit was being attempted and to hold off on splicing wires until notice. At around 9 AM Mx Ctl called stating that permit was denied and that only option now was cut wire bundle and splice.Multiple times Mechanic B asked if they were sure that they wanted this procedure done that once started the SB stated a 31 hr work time for a mechanic with experience on this system to perform task. They once again ensured that this was only option. MX Ctl was looking into finding a hangar to perform work. FBO denied access to hangar space. MX Ctl then suggested that mechanics get a couple tarps and throw them over the wing and borrow a salamander heater so that they could perform work. Mechanics thought this to be unsafe so they did not follow recommendation and continued to work in winds and low temperatures. Mechanic A then cut wires to start assembly of new wire bundle splice. During assembly procedure Mechanics A & B realized that wire identifiers sent in the kit were not for the lower Cannon plug but for upper cannon plug. Mechanics were concerned and called Hangar for advice. It then became aware to the mechanics that the SB only had instructions for splicing upper cannon plug. It has now been around 24 hours that Mechanics A and B have been on the clock. During this 24 hour period they have been through several Mx Controllers who did not have proper turn over. Mechanic B notified Mx Ctl that wire identifiers did not match up with lower cannon plug wire identifiers and wanted to know that if they could relabel wires with heat shrink printer that O/S maintenance provided. MX Ctl did not have an answer. During this time fatigue was really kicking in. Mechanics decided that they were exhausted and would like relief. MX Ctl then asked if there was any way they could quickly do splices to just limp that A/C to a MX base. Mechanic B then stated you do not understand this is a 31 hr task there is no quick way and noted that MX Ctl was notified several times that task was a 31 hr job. Mx Ctl then stated that a charter had been sent and that Mechanics could either wait for charter to arrive and fly back with charter or choose a hotel. Mechanics decided on flying in charter back to base. During the wait for charter to arrive mechanics filled out paperwork for workperformed. When asked on how to sign off cutting the wire bundle Mx Ctl gave them a REO for lower cannon plug splice. Mechanics did not have copy of REO sent in the SB packet sent in supply charter. Lap top computer sent with mechanics also does not have access to SB or REOs. Replacements arrived at 11pm and Mechanics A and B provided turn over to Mechanics C and D and proceeded to fly back to base.After landing Mechanics A and B talked to Supervisor about trip. Supervisor stated that he had recommended to MX Ctl several times that waiting for weather to improve for a ferry would be best option that if they were to make mechanics work in conditions that they were setting the mechanics up for 100% failure due to FAA dirty dozen suggestion on human factors. He stated then that MX Ctl said they could not do that. He also stated that when mechanic A was concerned over paperwork being improper for work performed that Mx Ctl stated that they did not have time to read over and not their job to read SB being sent to mechanics to perform. Mechanic A when returned was also informed that experienced avionic tech takes 8 Hours alone to assemble bundle and had no business doing this task in the elements. Mechanic A rested and as he return to following night it became more aware that a possible error could easily have resulted due to conditions that occurred during road trip.Events occurred because of MX Ctl extreme lack of communication during shift turnover. Freezing weather with moderate winds was also a factor. Fatigue of mechanics. Lack of system knowledge. Lack of experience.
Data retrieved from NASA's ASRS site 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.