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|
Attributes | |
ACN | 395681 |
Time | |
Date | 199801 |
Day | Wed |
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 | B727-200 |
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 | 395681 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 396125 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
On jan/xx/98 I checked installation of control columns on air carrier aircraft xyz per air carrier installation card yyxx they were both new control columns. I did a partial installation and signed the partial maintenance block at the bottom of the air carrier routine card. This is a 'C' block buy back per air carrier maintenance poi. This step must be approved by an inspector before the mechanic proceeds to next step. Inspection responsibility for work details are same as an 'I' block. Work progression details not visible once an item is complete are not an inspection responsibility per air carrier maintenance poi. I did not witness a protractor check due to the fact that quality check in process involvement was not a requirement of the above referenced procedure. Upon delivery of aircraft to the test flight crew the control column was found to be installed with the geared couplings misaligned by 1 tooth. Callback conversation with reporter revealed the following information: the reporter stated the control columns were installed using the air carrier maintenance manual which required progressive inspection as the job moved step by step. The reporter said the columns were installed by unlicensed and untrained technicians and the company was depending on the inspectors assigned to the work to prevent mistakes. The reporter stated the indexing of the control columns is accomplished with a rig pin and a protractor and is not an inspection item per the maintenance manual. The reporter said the rig pin was never used to index the control columns and as a result the columns were aft 7 degrees more than normal. The reporter stated it is common practice with this organization to use unlicensed and untrained technicians to accomplish the work and have it rechked by licensed mechanics or inspectors for signoff. Supplemental information from acn 396268: obviously a misunderstanding of the work cards and a lack of experience in performing this particular job resulted in the event that occurred.
Original NASA ASRS Text
Title: A B727-200 DURING A HVY MAINT VISIT HAD BOTH CTL COLUMNS INSTALLED AND RIGGED INCORRECTLY.
Narrative: ON JAN/XX/98 I CHKED INSTALLATION OF CTL COLUMNS ON ACR ACFT XYZ PER ACR INSTALLATION CARD YYXX THEY WERE BOTH NEW CTL COLUMNS. I DID A PARTIAL INSTALLATION AND SIGNED THE PARTIAL MAINT BLOCK AT THE BOTTOM OF THE ACR ROUTINE CARD. THIS IS A 'C' BLOCK BUY BACK PER ACR MAINT POI. THIS STEP MUST BE APPROVED BY AN INSPECTOR BEFORE THE MECH PROCEEDS TO NEXT STEP. INSPECTION RESPONSIBILITY FOR WORK DETAILS ARE SAME AS AN 'I' BLOCK. WORK PROGRESSION DETAILS NOT VISIBLE ONCE AN ITEM IS COMPLETE ARE NOT AN INSPECTION RESPONSIBILITY PER ACR MAINT POI. I DID NOT WITNESS A PROTRACTOR CHK DUE TO THE FACT THAT QUALITY CHK IN PROCESS INVOLVEMENT WAS NOT A REQUIREMENT OF THE ABOVE REFED PROC. UPON DELIVERY OF ACFT TO THE TEST FLC THE CTL COLUMN WAS FOUND TO BE INSTALLED WITH THE GEARED COUPLINGS MISALIGNED BY 1 TOOTH. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE CTL COLUMNS WERE INSTALLED USING THE ACR MAINT MANUAL WHICH REQUIRED PROGRESSIVE INSPECTION AS THE JOB MOVED STEP BY STEP. THE RPTR SAID THE COLUMNS WERE INSTALLED BY UNLICENSED AND UNTRAINED TECHNICIANS AND THE COMPANY WAS DEPENDING ON THE INSPECTORS ASSIGNED TO THE WORK TO PREVENT MISTAKES. THE RPTR STATED THE INDEXING OF THE CTL COLUMNS IS ACCOMPLISHED WITH A RIG PIN AND A PROTRACTOR AND IS NOT AN INSPECTION ITEM PER THE MAINT MANUAL. THE RPTR SAID THE RIG PIN WAS NEVER USED TO INDEX THE CTL COLUMNS AND AS A RESULT THE COLUMNS WERE AFT 7 DEGS MORE THAN NORMAL. THE RPTR STATED IT IS COMMON PRACTICE WITH THIS ORGANIZATION TO USE UNLICENSED AND UNTRAINED TECHNICIANS TO ACCOMPLISH THE WORK AND HAVE IT RECHKED BY LICENSED MECHS OR INSPECTORS FOR SIGNOFF. SUPPLEMENTAL INFO FROM ACN 396268: OBVIOUSLY A MISUNDERSTANDING OF THE WORK CARDS AND A LACK OF EXPERIENCE IN PERFORMING THIS PARTICULAR JOB RESULTED IN THE EVENT THAT OCCURRED.
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.