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|
Attributes | |
ACN | 455245 |
Time | |
Date | 199909 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-100 |
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 : 3 maintenance technician : 4 |
ASRS Report | 455245 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Situations | |
Publication | MAINTENANCE MANUAL |
Narrative:
I am reporting this event because I don't know if I was involved with the use of this procedure since its deletion on sep/xa/99. In the past, if an antiskid control valve was removed and reinstalled (not replaced), we used the attached maintenance manual bulletin to test the valve for continued service. As you can see, it has since been rescinded. During routine phase a checks, an inspector would sometimes find the valve mount bracket cracked and/or loose rivets in the bracket. This is the usual cause of the removal of the control valve and since the valve itself was not replaced, we used the procedures in the bulletin. Last night at the beginning of the shift (during the dock planning meeting), my supervisor announced to me and the other leads that he was not photocopying this procedure right out of the book, but instead he had several copies in his file cabinet and that he would sometimes grab one out and hand it to the lead or mechanic to use if he saw that we were very busy. Usually I photocopy it myself as I need it. But as my supervisor stated during the meeting, it is possible that he may have handed me or one of the mechanics working for me a copy from his files since the above time period.
Original NASA ASRS Text
Title: A DASH 8 WAS DISPATCHED IN NON COMPLIANCE, WITH AN ANTISKID VALVE REMOVED AND REINSTALLED AND AN OPS CHK OF SYS, USING OUT OF DATE PROC.
Narrative: I AM RPTING THIS EVENT BECAUSE I DON'T KNOW IF I WAS INVOLVED WITH THE USE OF THIS PROC SINCE ITS DELETION ON SEP/XA/99. IN THE PAST, IF AN ANTISKID CTL VALVE WAS REMOVED AND REINSTALLED (NOT REPLACED), WE USED THE ATTACHED MAINT MANUAL BULLETIN TO TEST THE VALVE FOR CONTINUED SVC. AS YOU CAN SEE, IT HAS SINCE BEEN RESCINDED. DURING ROUTINE PHASE A CHKS, AN INSPECTOR WOULD SOMETIMES FIND THE VALVE MOUNT BRACKET CRACKED AND/OR LOOSE RIVETS IN THE BRACKET. THIS IS THE USUAL CAUSE OF THE REMOVAL OF THE CTL VALVE AND SINCE THE VALVE ITSELF WAS NOT REPLACED, WE USED THE PROCS IN THE BULLETIN. LAST NIGHT AT THE BEGINNING OF THE SHIFT (DURING THE DOCK PLANNING MEETING), MY SUPVR ANNOUNCED TO ME AND THE OTHER LEADS THAT HE WAS NOT PHOTOCOPYING THIS PROC RIGHT OUT OF THE BOOK, BUT INSTEAD HE HAD SEVERAL COPIES IN HIS FILE CABINET AND THAT HE WOULD SOMETIMES GRAB ONE OUT AND HAND IT TO THE LEAD OR MECH TO USE IF HE SAW THAT WE WERE VERY BUSY. USUALLY I PHOTOCOPY IT MYSELF AS I NEED IT. BUT AS MY SUPVR STATED DURING THE MEETING, IT IS POSSIBLE THAT HE MAY HAVE HANDED ME OR ONE OF THE MECHS WORKING FOR ME A COPY FROM HIS FILES SINCE THE ABOVE TIME PERIOD.
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.