37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 443101 |
Time | |
Date | 199907 |
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 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 14 |
ASRS Report | 443101 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 443102 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : engineering procedure performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Change Order Authorization |
Narrative:
At start of shift, change order authority/authorized job cards did not exist in computer or on microfiche. Contacted maintenance for change order authority/authorized paperwork at XC30, was told maintenance would work on it. At XD00 lead mechanic told me, still no paperwork, we are not going to do the change order authority/authorized. At XV00 my co-worker arrived at aircraft with paperwork. Change order authority/authorized kits were ordered by lead mechanic. Co-worker and I went right to work reading the text of the change order authority/authorized job cards and referencing the illustrations but failed to utilize the TOD document at the beginning of the change order authority/authorized paperwork. The text at step 'G' said inspect latches for security but did not mention that item 'G' was a required inspection item. For this reason the change order authority/authorized was completed jul/fri/99, without required inspection item inspection or a completed TOD document. On jul/fri/99, at XY00, a union steward mentioned at briefing that another individual failed to have an inspector perform required inspection item inspection on the same change order authority/authorized but on another aircraft. I immediately coordinated with maintenance to locate my specific aircraft and have an inspector perform the required required inspection item inspection.
Original NASA ASRS Text
Title: AN AIRBUS 320 WAS DISPATCHED IN NON COMPLIANCE WITH THE ENG COWLING LATCH MODIFICATION ACCOMPLISHED BUT NOT INSPECTED.
Narrative: AT START OF SHIFT, CHANGE ORDER AUTH JOB CARDS DID NOT EXIST IN COMPUTER OR ON MICROFICHE. CONTACTED MAINT FOR CHANGE ORDER AUTH PAPERWORK AT XC30, WAS TOLD MAINT WOULD WORK ON IT. AT XD00 LEAD MECH TOLD ME, STILL NO PAPERWORK, WE ARE NOT GOING TO DO THE CHANGE ORDER AUTH. AT XV00 MY CO-WORKER ARRIVED AT ACFT WITH PAPERWORK. CHANGE ORDER AUTH KITS WERE ORDERED BY LEAD MECH. CO-WORKER AND I WENT RIGHT TO WORK READING THE TEXT OF THE CHANGE ORDER AUTH JOB CARDS AND REFING THE ILLUSTRATIONS BUT FAILED TO UTILIZE THE TOD DOCUMENT AT THE BEGINNING OF THE CHANGE ORDER AUTH PAPERWORK. THE TEXT AT STEP 'G' SAID INSPECT LATCHES FOR SECURITY BUT DID NOT MENTION THAT ITEM 'G' WAS A REQUIRED INSPECTION ITEM. FOR THIS REASON THE CHANGE ORDER AUTH WAS COMPLETED JUL/FRI/99, WITHOUT REQUIRED INSPECTION ITEM INSPECTION OR A COMPLETED TOD DOCUMENT. ON JUL/FRI/99, AT XY00, A UNION STEWARD MENTIONED AT BRIEFING THAT ANOTHER INDIVIDUAL FAILED TO HAVE AN INSPECTOR PERFORM REQUIRED INSPECTION ITEM INSPECTION ON THE SAME CHANGE ORDER AUTH BUT ON ANOTHER ACFT. I IMMEDIATELY COORDINATED WITH MAINT TO LOCATE MY SPECIFIC ACFT AND HAVE AN INSPECTOR PERFORM THE REQUIRED REQUIRED INSPECTION ITEM INSPECTION.
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.