37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 447432 |
Time | |
Date | 199908 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 5 maintenance technician : 18 |
ASRS Report | 447432 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : airframe technician : inspection authority technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure non adherence : company policies |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On aug/sat/99, I arrived at work and was assigned ship xyz with a #8 slat indication problem. The actuator had been replaced on the previous shift trying to correct the problem. The slat indication still was not working properly. I found a broken wire in the right wing, repaired it and corrected the problem. The mechanic who installed the actuator and the inspector both signed both the installation and the rii (required inspection item) in the corrective action block in the logbook. The work cards were also signed. The leak and operations checks were not cleared. I signed off the logbook and made the mistake of signing the rii block on the work card (an inspector only block). The aircraft was dispatched with no problems. I did perform the leak and operations check and documented that on the log sheet but did not have authority/authorized to sign the rii block on the work card. The late night shift inspection department foreman noticed that the rii on the leak and operations check had not been cleared and contacted the foreman on duty at the air carrier technical center. The aircraft was routed back to ZZZ for inspection and proper signature. I was the lead mechanic in charge of aircraft xyz at the time of this incident. Closer attention should have been paid to the job instruction cards after the maintenance was completed.
Original NASA ASRS Text
Title: A B727-200 WAS DISPATCHED IN NON COMPLIANCE AFTER #8 LEADING EDGE SLAT ACTUATOR WAS REPLACED AND THE REQUIRED INSPECTION WAS SIGNED BY AN UNAUTH PERSON.
Narrative: ON AUG/SAT/99, I ARRIVED AT WORK AND WAS ASSIGNED SHIP XYZ WITH A #8 SLAT INDICATION PROB. THE ACTUATOR HAD BEEN REPLACED ON THE PREVIOUS SHIFT TRYING TO CORRECT THE PROB. THE SLAT INDICATION STILL WAS NOT WORKING PROPERLY. I FOUND A BROKEN WIRE IN THE R WING, REPAIRED IT AND CORRECTED THE PROB. THE MECH WHO INSTALLED THE ACTUATOR AND THE INSPECTOR BOTH SIGNED BOTH THE INSTALLATION AND THE RII (REQUIRED INSPECTION ITEM) IN THE CORRECTIVE ACTION BLOCK IN THE LOGBOOK. THE WORK CARDS WERE ALSO SIGNED. THE LEAK AND OPS CHKS WERE NOT CLRED. I SIGNED OFF THE LOGBOOK AND MADE THE MISTAKE OF SIGNING THE RII BLOCK ON THE WORK CARD (AN INSPECTOR ONLY BLOCK). THE ACFT WAS DISPATCHED WITH NO PROBS. I DID PERFORM THE LEAK AND OPS CHK AND DOCUMENTED THAT ON THE LOG SHEET BUT DID NOT HAVE AUTH TO SIGN THE RII BLOCK ON THE WORK CARD. THE LATE NIGHT SHIFT INSPECTION DEPT FOREMAN NOTICED THAT THE RII ON THE LEAK AND OPS CHK HAD NOT BEEN CLRED AND CONTACTED THE FOREMAN ON DUTY AT THE ACR TECHNICAL CTR. THE ACFT WAS ROUTED BACK TO ZZZ FOR INSPECTION AND PROPER SIGNATURE. I WAS THE LEAD MECH IN CHARGE OF ACFT XYZ AT THE TIME OF THIS INCIDENT. CLOSER ATTN SHOULD HAVE BEEN PAID TO THE JOB INSTRUCTION CARDS AFTER THE MAINT WAS COMPLETED.
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.