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Attributes | |
ACN | 242091 |
Time | |
Date | 199303 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | other |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other oversight : supervisor |
Qualification | other other : other |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : assigned or threatened penalties faa : investigated |
Supplementary | |
Primary Problem | Chart Or Publication |
Air Traffic Incident | other |
Situations | |
Publication | Unspecified |
Narrative:
This is in reference to widebody transport upper left lateral centering control actuator change on mar/sun/93 at air carrier maintenance facility in sfo. This aircraft was released from maintenance without the notification of inspection for which I feel is due to insufficient maintenance manuals depicting inspection requirement. This aircraft also did not have a flight test, which is maintenance supervision's responsibility. Callback conversation with reporter revealed the following: the reporting mechanic for a major air carrier changed the lateral centering control actuator (lcca) on a widebody transport per the procedures listed in the maintenance manual. For this particular item in its manual, there is no mention of a higher inspection required or a flight test, although both are generally agreed to be required when there is a change to a flight control item. 4 employees, including the reporter's partner and supervisor, missed the fact that this change required an inspection by the quality control department. The aircraft flew 2 trans continental trips before someone woke up to the fact that an inspection was required. An inspection was made at lax where a company inspector found 6 discrepancies in the wheel well, most of which had nothing to do with the lateral centering control actuator. The reporter states that the FAA is on his employer about this incident, and his employer is passing all of the blame down to him. The reporter believes that the maintenance manuals, and especially the 'required inspection item' list should be changed to prevent this happening again.
Original NASA ASRS Text
Title: AN ACR'S MAINT PROC BROKE DOWN ALLOWING AN ACFT TO FLY WITHOUT AN INSPECTION AND FLT TEST.
Narrative: THIS IS IN REF TO WDB UPPER L LATERAL CENTERING CTL ACTUATOR CHANGE ON MAR/SUN/93 AT ACR MAINT FACILITY IN SFO. THIS ACFT WAS RELEASED FROM MAINT WITHOUT THE NOTIFICATION OF INSPECTION FOR WHICH I FEEL IS DUE TO INSUFFICIENT MAINT MANUALS DEPICTING INSPECTION REQUIREMENT. THIS ACFT ALSO DID NOT HAVE A FLT TEST, WHICH IS MAINT SUPERVISION'S RESPONSIBILITY. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: THE RPTING MECH FOR A MAJOR ACR CHANGED THE LATERAL CENTERING CTL ACTUATOR (LCCA) ON A WDB PER THE PROCS LISTED IN THE MAINT MANUAL. FOR THIS PARTICULAR ITEM IN ITS MANUAL, THERE IS NO MENTION OF A HIGHER INSPECTION REQUIRED OR A FLT TEST, ALTHOUGH BOTH ARE GENERALLY AGREED TO BE REQUIRED WHEN THERE IS A CHANGE TO A FLT CTL ITEM. 4 EMPLOYEES, INCLUDING THE RPTR'S PARTNER AND SUPVR, MISSED THE FACT THAT THIS CHANGE REQUIRED AN INSPECTION BY THE QUALITY CTL DEPT. THE ACFT FLEW 2 TRANS CONTINENTAL TRIPS BEFORE SOMEONE WOKE UP TO THE FACT THAT AN INSPECTION WAS REQUIRED. AN INSPECTION WAS MADE AT LAX WHERE A COMPANY INSPECTOR FOUND 6 DISCREPANCIES IN THE WHEEL WELL, MOST OF WHICH HAD NOTHING TO DO WITH THE LATERAL CENTERING CTL ACTUATOR. THE RPTR STATES THAT THE FAA IS ON HIS EMPLOYER ABOUT THIS INCIDENT, AND HIS EMPLOYER IS PASSING ALL OF THE BLAME DOWN TO HIM. THE RPTR BELIEVES THAT THE MAINT MANUALS, AND ESPECIALLY THE 'REQUIRED INSPECTION ITEM' LIST SHOULD BE CHANGED TO PREVENT THIS HAPPENING AGAIN.
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.