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|
Attributes | |
ACN | 450962 |
Time | |
Date | 199910 |
Day | Mon |
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 | B777-200 |
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 : powerplant technician : airframe |
Experience | maintenance technician : 8 |
ASRS Report | 450962 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 10 |
ASRS Report | 450965 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During troubleshooting of 'spoiler' EICAS message, #13 spoiler PCU was replaced per maintenance manual. (Ship xyz.) this occurred oct/mon/99, around XA00-XD00. The plane was subsequently released and flew without incident. Later oct/tue/99 afternoon it was brought to my attention that the list of rii (required inspection items) had changed last apr/xa/99, in our topp (technical operations policy and procedure manual), and where no rii was required previously for replacement in a line maintenance situation, it now was required. Upon discovery of our omission, I set up to have the inspection performed by quality assurance during its next transit to ZZZ, oct/wed/99. The inspection was performed and documented in aircraft logbook. I also initiated a maintenance advisory to bring heightened awareness to the rii change. Normally changes to topps are a 'read and sign,' so all are aware of the change. In my case, I had been involved with the B777 program, had no 'read and signs' for about the last yr, and was unaware of the change. A contributing factor would be no inspection or rii called for in maintenance manual.
Original NASA ASRS Text
Title: A B777-200ER WAS DISPATCHED IN NON COMPLIANCE WITH A #13 SPOILER PWR CTL UNTIL REPLACED WITHOUT THE REQUIRED INSPECTION ACCOMPLISHED.
Narrative: DURING TROUBLESHOOTING OF 'SPOILER' EICAS MESSAGE, #13 SPOILER PCU WAS REPLACED PER MAINT MANUAL. (SHIP XYZ.) THIS OCCURRED OCT/MON/99, AROUND XA00-XD00. THE PLANE WAS SUBSEQUENTLY RELEASED AND FLEW WITHOUT INCIDENT. LATER OCT/TUE/99 AFTERNOON IT WAS BROUGHT TO MY ATTN THAT THE LIST OF RII (REQUIRED INSPECTION ITEMS) HAD CHANGED LAST APR/XA/99, IN OUR TOPP (TECHNICAL OPS POLICY AND PROC MANUAL), AND WHERE NO RII WAS REQUIRED PREVIOUSLY FOR REPLACEMENT IN A LINE MAINT SIT, IT NOW WAS REQUIRED. UPON DISCOVERY OF OUR OMISSION, I SET UP TO HAVE THE INSPECTION PERFORMED BY QUALITY ASSURANCE DURING ITS NEXT TRANSIT TO ZZZ, OCT/WED/99. THE INSPECTION WAS PERFORMED AND DOCUMENTED IN ACFT LOGBOOK. I ALSO INITIATED A MAINT ADVISORY TO BRING HEIGHTENED AWARENESS TO THE RII CHANGE. NORMALLY CHANGES TO TOPPS ARE A 'READ AND SIGN,' SO ALL ARE AWARE OF THE CHANGE. IN MY CASE, I HAD BEEN INVOLVED WITH THE B777 PROGRAM, HAD NO 'READ AND SIGNS' FOR ABOUT THE LAST YR, AND WAS UNAWARE OF THE CHANGE. A CONTRIBUTING FACTOR WOULD BE NO INSPECTION OR RII CALLED FOR IN MAINT MANUAL.
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.