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|
Attributes | |
ACN | 453964 |
Time | |
Date | 199910 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
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 | Dash 8-200 |
Operating Under FAR Part | Part 121 |
Flight Plan | None |
Aircraft 2 | |
Flight Phase | ground : maintenance ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 453964 |
Person 2 | |
Function | maintenance : lead technician oversight : supervisor |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other |
Factors | |
Maintenance | contributing factor : lighting performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was removing screws from the panel forward of panel 264CR to perform the deice boot system check. 1 screw would not come out, so I removed panel 264CR to gain access to the nut plate of the bad screw. The nut plate was good, and I was able to remove the bad screw using pliers. I put the panel (264CR) back on and finger tightened the screws. I was planning ot finish tightening the screws with my speed handle, when a fellow work mate walked by. I asked if he could help me perform the deice boot check. It's a 2 man operation and it's customary to ask whoever is in the area to help you as soon as you see someone. After the check, I disconnected the air line and installed the panel for the deice boot line with new screws. I got down from the ladder and took a last glance up at the panel area. At that time I did not notice the other panel still had the screws loose because it was dark under the wing and the screws and panel were painted blue. I realize now that I forgot to tighten panel 264CR down. The contributing factors which may have caused my error were: lack of sleep prior to reporting to work. I had only 3 hours that day. Lack of nutrition. I hadn't eaten that day and was anticipating taking a break prior to this incident. I believe that if I had more lighting in the area, I would have caught my mistake. Also, if inspectors would make a walkaround check before these aircraft are sent out to the gates, this type of error may be caught in the future. I have been formally counseled and suspended from work without pay for 1 week thus far pending an ongoing FAA investigation into this matter.
Original NASA ASRS Text
Title: A MAINT TECHNICIAN FAILED TO COMPLETE TIGHTENING THE SCREWS ON AN UNDER WING PANEL AS REQUIRED.
Narrative: I WAS REMOVING SCREWS FROM THE PANEL FORWARD OF PANEL 264CR TO PERFORM THE DEICE BOOT SYS CHK. 1 SCREW WOULD NOT COME OUT, SO I REMOVED PANEL 264CR TO GAIN ACCESS TO THE NUT PLATE OF THE BAD SCREW. THE NUT PLATE WAS GOOD, AND I WAS ABLE TO REMOVE THE BAD SCREW USING PLIERS. I PUT THE PANEL (264CR) BACK ON AND FINGER TIGHTENED THE SCREWS. I WAS PLANNING OT FINISH TIGHTENING THE SCREWS WITH MY SPD HANDLE, WHEN A FELLOW WORK MATE WALKED BY. I ASKED IF HE COULD HELP ME PERFORM THE DEICE BOOT CHK. IT'S A 2 MAN OP AND IT'S CUSTOMARY TO ASK WHOEVER IS IN THE AREA TO HELP YOU AS SOON AS YOU SEE SOMEONE. AFTER THE CHK, I DISCONNECTED THE AIR LINE AND INSTALLED THE PANEL FOR THE DEICE BOOT LINE WITH NEW SCREWS. I GOT DOWN FROM THE LADDER AND TOOK A LAST GLANCE UP AT THE PANEL AREA. AT THAT TIME I DID NOT NOTICE THE OTHER PANEL STILL HAD THE SCREWS LOOSE BECAUSE IT WAS DARK UNDER THE WING AND THE SCREWS AND PANEL WERE PAINTED BLUE. I REALIZE NOW THAT I FORGOT TO TIGHTEN PANEL 264CR DOWN. THE CONTRIBUTING FACTORS WHICH MAY HAVE CAUSED MY ERROR WERE: LACK OF SLEEP PRIOR TO RPTING TO WORK. I HAD ONLY 3 HRS THAT DAY. LACK OF NUTRITION. I HADN'T EATEN THAT DAY AND WAS ANTICIPATING TAKING A BREAK PRIOR TO THIS INCIDENT. I BELIEVE THAT IF I HAD MORE LIGHTING IN THE AREA, I WOULD HAVE CAUGHT MY MISTAKE. ALSO, IF INSPECTORS WOULD MAKE A WALKAROUND CHK BEFORE THESE ACFT ARE SENT OUT TO THE GATES, THIS TYPE OF ERROR MAY BE CAUGHT IN THE FUTURE. I HAVE BEEN FORMALLY COUNSELED AND SUSPENDED FROM WORK WITHOUT PAY FOR 1 WK THUS FAR PENDING AN ONGOING FAA INVESTIGATION INTO THIS MATTER.
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.