Narrative:

I work as a line mechanic for a major air carrier. I was working a change order authorization (coa) on a widebody transport which entailed opening a panel on the upper surface of the wing above each engine pylon. As per the coa, I was to note the confign of a fuel line installation for the engineering department and then reinstall each upper wing panel. The coa provides 1 signoff for the notation of the confign of all 4 fuel lines, and 1 signoff for closing all 4 wing panels. These wing panels are sealed and have numerous fasteners which require much time to remove. I removed these panels, my lead mechanic informed me that there is a smaller panel on the lower surface of the wing that is much easier to remove and replace. Therefore, on pylon #3, I removed this small panel, noted the fuel line confign, and reinstalled the small panel. The task was made unnecessarily difficult by the engineer, therefore, I deviated from the paperwork in order to simplify the job and hasten completion. As any mechanic knows, it is better not to disturb the large wing panels unnecessarily. I was not able to finish pylon #4. The coa has only 1 signoff for the entire aircraft, therefore, I had to enter the work I completed on a non-routine writeup, noting by panel number, the 2 panels I removed on the left wing. A mechanic on the next shift proceeded with the coa. Apparently, he is an experienced mechanic who has done this coa by removing the small panels on the lower surface of the wing. He saw that I had completed pylon #3 and reinstalled the small panel. He completed pylon #4 in the same way. He must have assumed that I completed pylon #1 and pylon #2 in the same way, failing to note that the panel numbers I documented as having been removed on the left hand wing were not on the lower surface, but on the upper surface. He must have checked the lower surface of the left hand wing and saw no panels removed and therefore, cleared the writeup. The panels were left in place on the wing with a bag of screws attached. It should have been obvious that they were not installed. The widebody transport was dispatched and both panels separated from the wing on takeoff. This mechanic was negligent. Had he checked the panel numbers against a chart he would have seen that the panels are on the upper surface of the wing. However, I feel the root of the problem lies within the paperwork generated by the engineering department. The coa should have allowed a signoff for each task on each pylon. It would have been more readily apparent as to what had been completed and what had not been completed. Furthermore, had the engineer, when writing the coa, left his office and come down to the airplane he would have seen that there is a simple way to accomplish the task that does not involve the removal of large wing panels. The engineers make the paperwork unnecessarily complicated because they have no hands on experience. I believe that broad, all encompassing signoffs on paperwork are going to lead to further problems of this sort. Our profession is a profession of details. Reading additional directions, even if repetitious, and initialing next to these directions does not consume that much extra time and effort while giving a better picture of the progress made on the job. Supplemental information from acn 215938: I think this whole incident could have been avoided by a few simple procedures: 1) having the job card separate jobs per pylon so 1 mechanic doesn't take the blame for all. 2) having the job card changed to take off lower wing panels as usually done. 3) when not finishing a job card have actual legitimate writeups made as to what needs to be done. Callback conversation with reporter revealed the following information: the panels are about 3 ft by 3 ft. The air carrier is working to make the engineering department more aware of paperwork problems and solutions. It is technically illegal for mechanics to use the underwing shortcut in use even though it is done often. When more than 1 team of men is working on an aircraft, it is impossible for each of them to sign off the work he was responsible for using thepresent methods.

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Original NASA ASRS Text

Title: 2 NON STRUCTURAL WING PANELS FELL OFF WDB WHEN MAINT DID NOT FASTEN THEM AS THEY SHOULD HAVE.

Narrative: I WORK AS A LINE MECH FOR A MAJOR ACR. I WAS WORKING A CHANGE ORDER AUTHORIZATION (COA) ON A WDB WHICH ENTAILED OPENING A PANEL ON THE UPPER SURFACE OF THE WING ABOVE EACH ENG PYLON. AS PER THE COA, I WAS TO NOTE THE CONFIGN OF A FUEL LINE INSTALLATION FOR THE ENGINEERING DEPT AND THEN REINSTALL EACH UPPER WING PANEL. THE COA PROVIDES 1 SIGNOFF FOR THE NOTATION OF THE CONFIGN OF ALL 4 FUEL LINES, AND 1 SIGNOFF FOR CLOSING ALL 4 WING PANELS. THESE WING PANELS ARE SEALED AND HAVE NUMEROUS FASTENERS WHICH REQUIRE MUCH TIME TO REMOVE. I REMOVED THESE PANELS, MY LEAD MECH INFORMED ME THAT THERE IS A SMALLER PANEL ON THE LOWER SURFACE OF THE WING THAT IS MUCH EASIER TO REMOVE AND REPLACE. THEREFORE, ON PYLON #3, I REMOVED THIS SMALL PANEL, NOTED THE FUEL LINE CONFIGN, AND REINSTALLED THE SMALL PANEL. THE TASK WAS MADE UNNECESSARILY DIFFICULT BY THE ENGINEER, THEREFORE, I DEVIATED FROM THE PAPERWORK IN ORDER TO SIMPLIFY THE JOB AND HASTEN COMPLETION. AS ANY MECH KNOWS, IT IS BETTER NOT TO DISTURB THE LARGE WING PANELS UNNECESSARILY. I WAS NOT ABLE TO FINISH PYLON #4. THE COA HAS ONLY 1 SIGNOFF FOR THE ENTIRE ACFT, THEREFORE, I HAD TO ENTER THE WORK I COMPLETED ON A NON-ROUTINE WRITEUP, NOTING BY PANEL NUMBER, THE 2 PANELS I REMOVED ON THE L WING. A MECH ON THE NEXT SHIFT PROCEEDED WITH THE COA. APPARENTLY, HE IS AN EXPERIENCED MECH WHO HAS DONE THIS COA BY REMOVING THE SMALL PANELS ON THE LOWER SURFACE OF THE WING. HE SAW THAT I HAD COMPLETED PYLON #3 AND REINSTALLED THE SMALL PANEL. HE COMPLETED PYLON #4 IN THE SAME WAY. HE MUST HAVE ASSUMED THAT I COMPLETED PYLON #1 AND PYLON #2 IN THE SAME WAY, FAILING TO NOTE THAT THE PANEL NUMBERS I DOCUMENTED AS HAVING BEEN REMOVED ON THE L HAND WING WERE NOT ON THE LOWER SURFACE, BUT ON THE UPPER SURFACE. HE MUST HAVE CHKED THE LOWER SURFACE OF THE L HAND WING AND SAW NO PANELS REMOVED AND THEREFORE, CLRED THE WRITEUP. THE PANELS WERE LEFT IN PLACE ON THE WING WITH A BAG OF SCREWS ATTACHED. IT SHOULD HAVE BEEN OBVIOUS THAT THEY WERE NOT INSTALLED. THE WDB WAS DISPATCHED AND BOTH PANELS SEPARATED FROM THE WING ON TKOF. THIS MECH WAS NEGLIGENT. HAD HE CHKED THE PANEL NUMBERS AGAINST A CHART HE WOULD HAVE SEEN THAT THE PANELS ARE ON THE UPPER SURFACE OF THE WING. HOWEVER, I FEEL THE ROOT OF THE PROBLEM LIES WITHIN THE PAPERWORK GENERATED BY THE ENGINEERING DEPT. THE COA SHOULD HAVE ALLOWED A SIGNOFF FOR EACH TASK ON EACH PYLON. IT WOULD HAVE BEEN MORE READILY APPARENT AS TO WHAT HAD BEEN COMPLETED AND WHAT HAD NOT BEEN COMPLETED. FURTHERMORE, HAD THE ENGINEER, WHEN WRITING THE COA, LEFT HIS OFFICE AND COME DOWN TO THE AIRPLANE HE WOULD HAVE SEEN THAT THERE IS A SIMPLE WAY TO ACCOMPLISH THE TASK THAT DOES NOT INVOLVE THE REMOVAL OF LARGE WING PANELS. THE ENGINEERS MAKE THE PAPERWORK UNNECESSARILY COMPLICATED BECAUSE THEY HAVE NO HANDS ON EXPERIENCE. I BELIEVE THAT BROAD, ALL ENCOMPASSING SIGNOFFS ON PAPERWORK ARE GOING TO LEAD TO FURTHER PROBLEMS OF THIS SORT. OUR PROFESSION IS A PROFESSION OF DETAILS. READING ADDITIONAL DIRECTIONS, EVEN IF REPETITIOUS, AND INITIALING NEXT TO THESE DIRECTIONS DOES NOT CONSUME THAT MUCH EXTRA TIME AND EFFORT WHILE GIVING A BETTER PICTURE OF THE PROGRESS MADE ON THE JOB. SUPPLEMENTAL INFO FROM ACN 215938: I THINK THIS WHOLE INCIDENT COULD HAVE BEEN AVOIDED BY A FEW SIMPLE PROCS: 1) HAVING THE JOB CARD SEPARATE JOBS PER PYLON SO 1 MECH DOESN'T TAKE THE BLAME FOR ALL. 2) HAVING THE JOB CARD CHANGED TO TAKE OFF LOWER WING PANELS AS USUALLY DONE. 3) WHEN NOT FINISHING A JOB CARD HAVE ACTUAL LEGITIMATE WRITEUPS MADE AS TO WHAT NEEDS TO BE DONE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE PANELS ARE ABOUT 3 FT BY 3 FT. THE ACR IS WORKING TO MAKE THE ENGINEERING DEPT MORE AWARE OF PAPERWORK PROBLEMS AND SOLUTIONS. IT IS TECHNICALLY ILLEGAL FOR MECHS TO USE THE UNDERWING SHORTCUT IN USE EVEN THOUGH IT IS DONE OFTEN. WHEN MORE THAN 1 TEAM OF MEN IS WORKING ON AN ACFT, IT IS IMPOSSIBLE FOR EACH OF THEM TO SIGN OFF THE WORK HE WAS RESPONSIBLE FOR USING THEPRESENT METHODS.

Data retrieved from NASA's ASRS site as of July 2007 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.