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A B747-200 was dispatched with a defective cockpit handset installed.
| Attributes | |
| ACN | 381162 |
| Time | |
| Date | 199709 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz |
| State Reference | US |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B747-100 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | other |
| Flight Plan | None |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Qualification | other other : other |
| ASRS Report | 381162 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Qualification | other other : other |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : far non adherence : published procedure other anomaly other |
| Independent Detector | other other : unspecified |
| Resolutory Action | none taken : detected after the fact |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Aircraft |
| Air Traffic Incident | other |
Narrative:
On sep/fri/97, I was assigned to an air carrier B747-200 ship XXX to perform turnaround maintenance service. In addition to a main landing gear tire change and several cabin discrepancies, there were 2 flight deck discrepancies. One was an attitude deviation indicator that was sticking and the other was log page abc relating to the flight deck interphone handset. This handset is a non deferrable (no-go) item, as it is used to relay emergency instructions, PA announcements and to communicate with the cabin crew members in the event of an emergency. The log page abc discrepancy was documented as 'cockpit interphone handset receiver is intermittent, and buttons do not seem to work properly.' I was instructed by my lead to remove the handset from ship xyz and documented such removal on log page YYY as 'removed pilot's handset for ship XXX.' I then installed the removed handset in ship XXX and functional tested the installation, which tested ok. During this time, approximately XX15 hours, maintenance stores was advised that another handset was needed, to replace the one removed from ship xyz. The removed/defective handset from ship XXX was placed on the stores clerk's desk and I verbally advised him that it was a defective part. The lead mechanic was also advised that the removed part was defective (he instructed me to remove the handset from ship xyz). At approximately XA00 hours I was advised and reprimanded by the lead mechanic that due to my negligence, of not installing an unserviceable parts tag on the unserviceable handset, it had been installed on ship xyz as documented on the log page YYY, of ship xyz by mechanic JJJ. My lead mechanic advised me that due to my failure to attach an unserviceable parts tag to the handset, the aircraft has departed with an unserviceable part. In the event that this defective part causes an in-flight emergency to further deteriorate, I am filing the 'NASA' form with your agency.
Original NASA ASRS Text
Title: A B747-200 WAS DISPATCHED WITH A DEFECTIVE COCKPIT HANDSET INSTALLED.
Narrative: ON SEP/FRI/97, I WAS ASSIGNED TO AN ACR B747-200 SHIP XXX TO PERFORM TURNAROUND MAINT SVC. IN ADDITION TO A MAIN LNDG GEAR TIRE CHANGE AND SEVERAL CABIN DISCREPANCIES, THERE WERE 2 FLT DECK DISCREPANCIES. ONE WAS AN ATTITUDE DEV INDICATOR THAT WAS STICKING AND THE OTHER WAS LOG PAGE ABC RELATING TO THE FLT DECK INTERPHONE HANDSET. THIS HANDSET IS A NON DEFERRABLE (NO-GO) ITEM, AS IT IS USED TO RELAY EMER INSTRUCTIONS, PA ANNOUNCEMENTS AND TO COMMUNICATE WITH THE CABIN CREW MEMBERS IN THE EVENT OF AN EMER. THE LOG PAGE ABC DISCREPANCY WAS DOCUMENTED AS 'COCKPIT INTERPHONE HANDSET RECEIVER IS INTERMITTENT, AND BUTTONS DO NOT SEEM TO WORK PROPERLY.' I WAS INSTRUCTED BY MY LEAD TO REMOVE THE HANDSET FROM SHIP XYZ AND DOCUMENTED SUCH REMOVAL ON LOG PAGE YYY AS 'REMOVED PLT'S HANDSET FOR SHIP XXX.' I THEN INSTALLED THE REMOVED HANDSET IN SHIP XXX AND FUNCTIONAL TESTED THE INSTALLATION, WHICH TESTED OK. DURING THIS TIME, APPROX XX15 HRS, MAINT STORES WAS ADVISED THAT ANOTHER HANDSET WAS NEEDED, TO REPLACE THE ONE REMOVED FROM SHIP XYZ. THE REMOVED/DEFECTIVE HANDSET FROM SHIP XXX WAS PLACED ON THE STORES CLERK'S DESK AND I VERBALLY ADVISED HIM THAT IT WAS A DEFECTIVE PART. THE LEAD MECH WAS ALSO ADVISED THAT THE REMOVED PART WAS DEFECTIVE (HE INSTRUCTED ME TO REMOVE THE HANDSET FROM SHIP XYZ). AT APPROX XA00 HRS I WAS ADVISED AND REPRIMANDED BY THE LEAD MECH THAT DUE TO MY NEGLIGENCE, OF NOT INSTALLING AN UNSERVICEABLE PARTS TAG ON THE UNSERVICEABLE HANDSET, IT HAD BEEN INSTALLED ON SHIP XYZ AS DOCUMENTED ON THE LOG PAGE YYY, OF SHIP XYZ BY MECH JJJ. MY LEAD MECH ADVISED ME THAT DUE TO MY FAILURE TO ATTACH AN UNSERVICEABLE PARTS TAG TO THE HANDSET, THE ACFT HAS DEPARTED WITH AN UNSERVICEABLE PART. IN THE EVENT THAT THIS DEFECTIVE PART CAUSES AN INFLT EMER TO FURTHER DETERIORATE, I AM FILING THE 'NASA' FORM WITH YOUR AGENCY.
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.