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|
Attributes | |
ACN | 278630 |
Time | |
Date | 199407 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : hnl |
State Reference | HI |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 278630 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
Aircraft returned to hnl left wing gear would not retract all the way up. Coa -- paperwork provided to shift lead from station maintenance controller, the shift lead gave the paperwork to another mechanic. I was asked to help this mechanic to install a left wing gear down lock actuator. Per shift lead -- the other mechanic ordered the down lock actuator and we proceeded to replace the actuator, noting the coa was a change order. I asked the other mechanic briefly about the maintenance release number not matching the one removed, however, the paperwork in hand, now oily with skydrol. I had noticed the maintenance release number. The number matched to the one installed. However when I went to lunch and cleaned myself of skydrol, the lead plus other mechanic found the paperwork wrong. The paperwork was for a body gear downlock. The lead plus mechanic notified station maintenance controller which did not say much of the finding. The paperwork was switched and the other mechanic signed it. I came back from lunch not knowing of switch and was told by head mechanic just sign next to the mechanic I had helped. Aircraft released by lead mechanic and aircraft flew out with a body gear installed to left wing gear, and the left wing could not retract all the way. Factors: station maintenance controllers provide paperwork packages for oncoming shift, leading to this situation. The maintenance controller and lead did not go over work assignment to be issued. There was no inspection block signoff for the rii. Therefore no inspection done. Human factors: feeling that the maintenance controller is best aware of paperwork assignments and the lead also. I trusted the paperwork to be true as I only helped and did not have paperwork given to me. Maintenance controller should have done more to make sure that maintenance repair was fully covered by all individuals, being that he was notified of error.
Original NASA ASRS Text
Title: WRONG LNDG GEAR ACTUATOR INSTALLATION
Narrative: ACFT RETURNED TO HNL L WING GEAR WOULD NOT RETRACT ALL THE WAY UP. COA -- PAPERWORK PROVIDED TO SHIFT LEAD FROM STATION MAINT CTLR, THE SHIFT LEAD GAVE THE PAPERWORK TO ANOTHER MECH. I WAS ASKED TO HELP THIS MECH TO INSTALL A L WING GEAR DOWN LOCK ACTUATOR. PER SHIFT LEAD -- THE OTHER MECH ORDERED THE DOWN LOCK ACTUATOR AND WE PROCEEDED TO REPLACE THE ACTUATOR, NOTING THE COA WAS A CHANGE ORDER. I ASKED THE OTHER MECH BRIEFLY ABOUT THE MAINT RELEASE NUMBER NOT MATCHING THE ONE REMOVED, HOWEVER, THE PAPERWORK IN HAND, NOW OILY WITH SKYDROL. I HAD NOTICED THE MAINT RELEASE NUMBER. THE NUMBER MATCHED TO THE ONE INSTALLED. HOWEVER WHEN I WENT TO LUNCH AND CLEANED MYSELF OF SKYDROL, THE LEAD PLUS OTHER MECH FOUND THE PAPERWORK WRONG. THE PAPERWORK WAS FOR A BODY GEAR DOWNLOCK. THE LEAD PLUS MECH NOTIFIED STATION MAINT CTLR WHICH DID NOT SAY MUCH OF THE FINDING. THE PAPERWORK WAS SWITCHED AND THE OTHER MECH SIGNED IT. I CAME BACK FROM LUNCH NOT KNOWING OF SWITCH AND WAS TOLD BY HEAD MECH JUST SIGN NEXT TO THE MECH I HAD HELPED. ACFT RELEASED BY LEAD MECH AND ACFT FLEW OUT WITH A BODY GEAR INSTALLED TO L WING GEAR, AND THE L WING COULD NOT RETRACT ALL THE WAY. FACTORS: STATION MAINT CTLRS PROVIDE PAPERWORK PACKAGES FOR ONCOMING SHIFT, LEADING TO THIS SIT. THE MAINT CTLR AND LEAD DID NOT GO OVER WORK ASSIGNMENT TO BE ISSUED. THERE WAS NO INSPECTION BLOCK SIGNOFF FOR THE RII. THEREFORE NO INSPECTION DONE. HUMAN FACTORS: FEELING THAT THE MAINT CTLR IS BEST AWARE OF PAPERWORK ASSIGNMENTS AND THE LEAD ALSO. I TRUSTED THE PAPERWORK TO BE TRUE AS I ONLY HELPED AND DID NOT HAVE PAPERWORK GIVEN TO ME. MAINT CTLR SHOULD HAVE DONE MORE TO MAKE SURE THAT MAINT REPAIR WAS FULLY COVERED BY ALL INDIVIDUALS, BEING THAT HE WAS NOTIFIED OF ERROR.
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.