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|
Attributes | |
ACN | 453332 |
Time | |
Date | 199910 |
Day | Sun |
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 | B757-200 |
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 |
ASRS Report | 453332 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : published procedure |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The way the job cards sign off for this task on ETOPS type aircraft for my carrier, was blended in with a task atop of it on the signoff sheet. I placed off, all the task to be performed, a water chlorination task was not assigned due to the misplaced way it was on the signoff sheet. I overlooked this task at approximately XA30 while preparing to move this aircraft. It was brought to my attention: task was not assigned. I took the sheet, signed it. Told the mechanic not to worry 'I'll take care of it' and guess they will drink bottle water (I will defer it later). As I finished this I was told that a company we provide overnight maintenance needed their plane now for an XC10 departure. Since I was the only taxi person for type aircraft, I took the plane to the needed gate and arrived back at my hangar at XD00. Have now forgotten to defer the water chlorination, and still with another aircraft that I had to get out. While I was away, an upgrade lead placed my work pack in the complete check. A supervisor questioned me on the water, and I told him it was not done and I'm going to get a defer on it. He wanted it done. Tried to get men to do task, since it was end of tour. No takers. Went and deferred task. Contributing factor: getting too involved in too many tasks.
Original NASA ASRS Text
Title: A B757-200 SCHEDULED POTABLE WATER SYS CHLORINATION WAS NOT ACCOMPLISHED DUE TO JOB CARD DEFICIENCY AND LEAD TECHNICIAN INCOMPETENCE.
Narrative: THE WAY THE JOB CARDS SIGN OFF FOR THIS TASK ON ETOPS TYPE ACFT FOR MY CARRIER, WAS BLENDED IN WITH A TASK ATOP OF IT ON THE SIGNOFF SHEET. I PLACED OFF, ALL THE TASK TO BE PERFORMED, A WATER CHLORINATION TASK WAS NOT ASSIGNED DUE TO THE MISPLACED WAY IT WAS ON THE SIGNOFF SHEET. I OVERLOOKED THIS TASK AT APPROX XA30 WHILE PREPARING TO MOVE THIS ACFT. IT WAS BROUGHT TO MY ATTN: TASK WAS NOT ASSIGNED. I TOOK THE SHEET, SIGNED IT. TOLD THE MECH NOT TO WORRY 'I'LL TAKE CARE OF IT' AND GUESS THEY WILL DRINK BOTTLE WATER (I WILL DEFER IT LATER). AS I FINISHED THIS I WAS TOLD THAT A COMPANY WE PROVIDE OVERNIGHT MAINT NEEDED THEIR PLANE NOW FOR AN XC10 DEP. SINCE I WAS THE ONLY TAXI PERSON FOR TYPE ACFT, I TOOK THE PLANE TO THE NEEDED GATE AND ARRIVED BACK AT MY HANGAR AT XD00. HAVE NOW FORGOTTEN TO DEFER THE WATER CHLORINATION, AND STILL WITH ANOTHER ACFT THAT I HAD TO GET OUT. WHILE I WAS AWAY, AN UPGRADE LEAD PLACED MY WORK PACK IN THE COMPLETE CHK. A SUPVR QUESTIONED ME ON THE WATER, AND I TOLD HIM IT WAS NOT DONE AND I'M GOING TO GET A DEFER ON IT. HE WANTED IT DONE. TRIED TO GET MEN TO DO TASK, SINCE IT WAS END OF TOUR. NO TAKERS. WENT AND DEFERRED TASK. CONTRIBUTING FACTOR: GETTING TOO INVOLVED IN TOO MANY TASKS.
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.