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|
Attributes | |
ACN | 434860 |
Time | |
Date | 199904 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : iso.tower |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 1 maintenance technician : 8 |
ASRS Report | 434860 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 19 |
ASRS Report | 435002 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : technician |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Company |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Engine Change Job Cards |
Narrative:
On apr/xa/99 I was assigned as lead mechanic on aircraft xyz for the #1 engine change. Upon inspection of the engine to be installed serial number xaxax, it was determined by myself and the assigned inspector to have been properly configured for the aircraft. The engine was then installed by another shift and preflted. To the best of my knowledge all checks were normal. On apr/xa/99 it was brought to my attention that the engine card deck operation zyyz step #1 has been 'not applicable'ed' in error. This was caused by an inadequate, clear presentation of cards which give several different confign possibilities of aircraft harness types. These are spread out over several cards in a single change card deck. It gives some question as to which cards are applicable to sign. It was later found that aircraft xyz experienced a #1 engine fire detonation fault. This was due to the type of loop installed. The aircraft made several flts and passed tests performed by crew with preflts. This was learned when it would not pass testing apr/xd/99 in abc. This was not an intentional error and I would like to see changes made to more clearly define the appropriate fire loop checking on the engine change card decks.
Original NASA ASRS Text
Title: A B727-200 WAS DISPATCHED IN NON COMPLIANCE DUE TO THE WRONG FIRE WARNING LOOP INSTALLED ON #1 ENG CAUSED BY CONFLICTING AND CONFUSING ENG CHANGE JOB CARDS.
Narrative: ON APR/XA/99 I WAS ASSIGNED AS LEAD MECH ON ACFT XYZ FOR THE #1 ENG CHANGE. UPON INSPECTION OF THE ENG TO BE INSTALLED SERIAL NUMBER XAXAX, IT WAS DETERMINED BY MYSELF AND THE ASSIGNED INSPECTOR TO HAVE BEEN PROPERLY CONFIGURED FOR THE ACFT. THE ENG WAS THEN INSTALLED BY ANOTHER SHIFT AND PREFLTED. TO THE BEST OF MY KNOWLEDGE ALL CHKS WERE NORMAL. ON APR/XA/99 IT WAS BROUGHT TO MY ATTN THAT THE ENG CARD DECK OP ZYYZ STEP #1 HAS BEEN 'NOT APPLICABLE'ED' IN ERROR. THIS WAS CAUSED BY AN INADEQUATE, CLR PRESENTATION OF CARDS WHICH GIVE SEVERAL DIFFERENT CONFIGN POSSIBILITIES OF ACFT HARNESS TYPES. THESE ARE SPREAD OUT OVER SEVERAL CARDS IN A SINGLE CHANGE CARD DECK. IT GIVES SOME QUESTION AS TO WHICH CARDS ARE APPLICABLE TO SIGN. IT WAS LATER FOUND THAT ACFT XYZ EXPERIENCED A #1 ENG FIRE DETONATION FAULT. THIS WAS DUE TO THE TYPE OF LOOP INSTALLED. THE ACFT MADE SEVERAL FLTS AND PASSED TESTS PERFORMED BY CREW WITH PREFLTS. THIS WAS LEARNED WHEN IT WOULD NOT PASS TESTING APR/XD/99 IN ABC. THIS WAS NOT AN INTENTIONAL ERROR AND I WOULD LIKE TO SEE CHANGES MADE TO MORE CLRLY DEFINE THE APPROPRIATE FIRE LOOP CHKING ON THE ENG CHANGE CARD DECKS.
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.