37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1756044 |
Time | |
Date | 202008 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Person 2 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Deviation - Procedural Maintenance |
Narrative:
During my shift [I] was tasked to complete slat adjustment on #11 slat. A few hours in it was noticed that the outboard target on the auxiliary track was not lining up with its sensor. A quick glance at the adjacent slat seemed to confirm that the targets were not in the correct position. Being under pressure to get the aircraft out we swapped the positions and pressed on with the adjustment test without doing our due diligence and verifying with the amm (aircraft maintenance manual). Several hours later we were about to lose the 2nd shift inspector for the night so we had to rush to catch up paperwork for his stamp before he left for the night and we continued on with the 3rd shift. At that point we were so focused on the adjustment steps we had done we forgot about the target swap and failed to document it. Had we remembered; the improper installation would have been caught and corrected and this problem never would have occurred. We continued on with adjustments for several more hours doing sensor gap checks and pseu/fseu (proximity sensors electronics unit/flap slat electronics unit) electrical checks that all passed.we were under incredible pressure to get the plane out. Because of a lack of training and ability in our 1st and 3rd shifts; we were not allowed to turn any of this work over to them and so [that day we] were pressured to work it until it's done. [A] lack of accountability in some members of all shifts who only give the bare minimum of effort translates into a lot of pressure put on just a few leading to poor morale; fatigue and lack of focus that translates into mistakes. Being told that we have to get the majority done so that the next shift only has to worry about putting on panels because 'they don't know how to do it' is getting to be a frustratingly common occurrence. It leads to [having] tunnel vision on getting the job done that critical steps get missed. Things like just catch the paperwork up at the end so you can keep your momentum become standard instead of documenting as you go. Even when things outside of our control occur; inflexibility in the deadline and an 'it is what it is' attitude conveyed from above keeps the pressure on. This check was no different in that a ramp incident with our next AC (aircraft) dropped it here ahead of schedule; so there was no give on our launch date even with some late findings and when it was obvious we weren't going to make it was just time to turn up the heat. Day 1 of a new check isn't much better as we are told to work as much as possible early to avoid the crunch; but then we do not receive a lot of our required parts until the end of the check. So no matter what we always feel behind.[I suggest] first; better training on all shifts so work like this can be continuously worked instead of left to only one group. That could have a big impact on the pressures of being rushed at the end of every C check. Second would be real accountability for underperforming staff who by lack of effort are putting more work on others. Everyone pulling equally would improve moral and lead to less crunch at the end of a C check. [Another suggestion is] better [and] timelier sourcing of parts/materials to once again; better space our work flow so we are not always up against it at the 11th hour. These things would go a long way to reducing the stress that impacts morale and invites mistakes. Another thing would be to place a large emphasis on mechanics using partial sheets as they are intended to be used. We tend to get complacent about just working and catching the paperwork up at the end and this leads to things being missed or forgotten. Individual mechanics making the entry at the time the inspector witnesses a step and having it bought then will eliminate the possibility of things being missed or forgotten.
Original NASA ASRS Text
Title: Aircraft Technicians reported that proper documentation was not done following slat repair.
Narrative: During my shift [I] was tasked to complete slat adjustment on #11 slat. A few hours in it was noticed that the outboard target on the auxiliary track was not lining up with its sensor. A quick glance at the adjacent slat seemed to confirm that the targets were not in the correct position. Being under pressure to get the aircraft out we swapped the positions and pressed on with the adjustment test without doing our due diligence and verifying with the AMM (Aircraft Maintenance Manual). Several hours later we were about to lose the 2nd shift inspector for the night so we had to rush to catch up paperwork for his stamp before he left for the night and we continued on with the 3rd shift. At that point we were so focused on the adjustment steps we had done we forgot about the target swap and failed to document it. Had we remembered; the improper installation would have been caught and corrected and this problem never would have occurred. We continued on with adjustments for several more hours doing sensor gap checks and PSEU/FSEU (Proximity Sensors Electronics Unit/Flap Slat Electronics Unit) electrical checks that all passed.We were under incredible pressure to get the plane out. Because of a lack of training and ability in our 1st and 3rd shifts; we were not allowed to turn any of this work over to them and so [that day we] were pressured to work it until it's done. [A] lack of accountability in some members of all shifts who only give the bare minimum of effort translates into a lot of pressure put on just a few leading to poor morale; fatigue and lack of focus that translates into mistakes. Being told that we have to get the majority done so that the next shift only has to worry about putting on panels because 'they don't know how to do it' is getting to be a frustratingly common occurrence. It leads to [having] tunnel vision on getting the job done that critical steps get missed. Things like just catch the paperwork up at the end so you can keep your momentum become standard instead of documenting as you go. Even when things outside of our control occur; inflexibility in the deadline and an 'it is what it is' attitude conveyed from above keeps the pressure on. This check was no different in that a ramp incident with our next AC (Aircraft) dropped it here ahead of schedule; so there was no give on our launch date even with some late findings and when it was obvious we weren't going to make it was just time to turn up the heat. Day 1 of a new check isn't much better as we are told to work as much as possible early to avoid the crunch; but then we do not receive a lot of our required parts until the end of the check. So no matter what we always feel behind.[I suggest] first; better training on all shifts so work like this can be continuously worked instead of left to only one group. That could have a big impact on the pressures of being rushed at the end of every C check. Second would be real accountability for underperforming staff who by lack of effort are putting more work on others. Everyone pulling equally would improve moral and lead to less crunch at the end of a C check. [Another suggestion is] better [and] timelier sourcing of parts/materials to once again; better space our work flow so we are not always up against it at the 11th hour. These things would go a long way to reducing the stress that impacts morale and invites mistakes. Another thing would be to place a large emphasis on mechanics using partial sheets as they are intended to be used. We tend to get complacent about just working and catching the paperwork up at the end and this leads to things being missed or forgotten. Individual mechanics making the entry at the time the inspector witnesses a step and having it bought then will eliminate the possibility of things being missed or forgotten.
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.