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|
Attributes | |
ACN | 456430 |
Time | |
Date | 199911 |
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 | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ord.tower |
Operator | common carrier : air taxi |
Make Model Name | Jet Ranger/Kiowa/206 |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | company : air taxi |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 3 maintenance technician : 14 |
ASRS Report | 456430 |
Person 2 | |
Affiliation | company : air taxi |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was employed as a lead mechanic for air carrier at one of their field bases. There was no on-site manager. We work 7 days on and 7 days off, so there is another lead mechanic and crew during my 7 days off. On nov/xa/99, I received a call from the chief inspector stating that the starter generator on xyz was showing overdue for overhaul. He asked me to check into it, and if it was a matter of lost paperwork, forward said paperwork to records. I found that the hard copy of the computer status sheets, which remains in our maintenance office, had been marked to show compliance with the overhaul. The maintenance tracking records, which we keep also, showed compliance. At the next return of the aircraft, I checked the serial number of the generator, and found that it was in fact overdue. The copy of the status sheet which stays with the aircraft was correct in showing the overdue situation, and the maintenance due list in the logbook made no mention of the starter (this would normally indicate compliance). This means that before the call from records, the only document that correctly indicated the starter status was the computer status run which stayed with the aircraft. I proceeded to remove the starter from service, and installed a svcable generator. I was not a manager nor was I trained to be one. As a lead mechanic with 8 aircraft at my facility, I was in fact performing an almost identical function except for matters relating to personnel. Without the training to be a manager I had to go by what I had seen the other mgrs I had worked for do in similar sits. Though not officially approved by the company, the example I followed was to backdate the installation of the starter to make it appear that it was installed before it became overdue. I hardly gave it a thought because it was unofficially 'SOP.' on nov/xd/99, I received a call from records indicating that they received the revised paperwork and that the 400 hour brush inspection for the new starter was 19 hours overdue. I called inspections and they talked to the director of field maintenance who subsequently called me. He asked me some questions and went to do research. He then called with more questions, at which time I volunteered that the brushes were not overdue because the date of the starter installation had been backdated. I was subsequently terminated from my employment. In my opinion, the original overflt was missed because the aircraft was based offshore and returned for maintenance on only 2 nights of the week. The first time it arrived was a day before new status sheets were distributed. Its onboard records could not be updated until its second appearance, which was on our final work day. We were always busy on this day trying to make sure all was ready for the oncoming work crew. In addition, the bell 407 has a large amount of recurring inspections which makes for a complicated and messy looking maintenance due sheet. As for the on-base maintenance records being incorrect, this was done by my opposites and I have no explanation why. The backdating was due to improper (actually no) training for the lead mechanic position, and by the practice being winked at (unofficially approved of) by those who were mgrs.
Original NASA ASRS Text
Title: A BELL 407 HELI WAS OPERATED IN NON COMPLIANCE WITH THE STARTER GENERATOR OVERDUE FOR OVERHAUL.
Narrative: I WAS EMPLOYED AS A LEAD MECH FOR ACR AT ONE OF THEIR FIELD BASES. THERE WAS NO ON-SITE MGR. WE WORK 7 DAYS ON AND 7 DAYS OFF, SO THERE IS ANOTHER LEAD MECH AND CREW DURING MY 7 DAYS OFF. ON NOV/XA/99, I RECEIVED A CALL FROM THE CHIEF INSPECTOR STATING THAT THE STARTER GENERATOR ON XYZ WAS SHOWING OVERDUE FOR OVERHAUL. HE ASKED ME TO CHK INTO IT, AND IF IT WAS A MATTER OF LOST PAPERWORK, FORWARD SAID PAPERWORK TO RECORDS. I FOUND THAT THE HARD COPY OF THE COMPUTER STATUS SHEETS, WHICH REMAINS IN OUR MAINT OFFICE, HAD BEEN MARKED TO SHOW COMPLIANCE WITH THE OVERHAUL. THE MAINT TRACKING RECORDS, WHICH WE KEEP ALSO, SHOWED COMPLIANCE. AT THE NEXT RETURN OF THE ACFT, I CHKED THE SERIAL NUMBER OF THE GENERATOR, AND FOUND THAT IT WAS IN FACT OVERDUE. THE COPY OF THE STATUS SHEET WHICH STAYS WITH THE ACFT WAS CORRECT IN SHOWING THE OVERDUE SIT, AND THE MAINT DUE LIST IN THE LOGBOOK MADE NO MENTION OF THE STARTER (THIS WOULD NORMALLY INDICATE COMPLIANCE). THIS MEANS THAT BEFORE THE CALL FROM RECORDS, THE ONLY DOCUMENT THAT CORRECTLY INDICATED THE STARTER STATUS WAS THE COMPUTER STATUS RUN WHICH STAYED WITH THE ACFT. I PROCEEDED TO REMOVE THE STARTER FROM SVC, AND INSTALLED A SVCABLE GENERATOR. I WAS NOT A MGR NOR WAS I TRAINED TO BE ONE. AS A LEAD MECH WITH 8 ACFT AT MY FACILITY, I WAS IN FACT PERFORMING AN ALMOST IDENTICAL FUNCTION EXCEPT FOR MATTERS RELATING TO PERSONNEL. WITHOUT THE TRAINING TO BE A MGR I HAD TO GO BY WHAT I HAD SEEN THE OTHER MGRS I HAD WORKED FOR DO IN SIMILAR SITS. THOUGH NOT OFFICIALLY APPROVED BY THE COMPANY, THE EXAMPLE I FOLLOWED WAS TO BACKDATE THE INSTALLATION OF THE STARTER TO MAKE IT APPEAR THAT IT WAS INSTALLED BEFORE IT BECAME OVERDUE. I HARDLY GAVE IT A THOUGHT BECAUSE IT WAS UNOFFICIALLY 'SOP.' ON NOV/XD/99, I RECEIVED A CALL FROM RECORDS INDICATING THAT THEY RECEIVED THE REVISED PAPERWORK AND THAT THE 400 HR BRUSH INSPECTION FOR THE NEW STARTER WAS 19 HRS OVERDUE. I CALLED INSPECTIONS AND THEY TALKED TO THE DIRECTOR OF FIELD MAINT WHO SUBSEQUENTLY CALLED ME. HE ASKED ME SOME QUESTIONS AND WENT TO DO RESEARCH. HE THEN CALLED WITH MORE QUESTIONS, AT WHICH TIME I VOLUNTEERED THAT THE BRUSHES WERE NOT OVERDUE BECAUSE THE DATE OF THE STARTER INSTALLATION HAD BEEN BACKDATED. I WAS SUBSEQUENTLY TERMINATED FROM MY EMPLOYMENT. IN MY OPINION, THE ORIGINAL OVERFLT WAS MISSED BECAUSE THE ACFT WAS BASED OFFSHORE AND RETURNED FOR MAINT ON ONLY 2 NIGHTS OF THE WK. THE FIRST TIME IT ARRIVED WAS A DAY BEFORE NEW STATUS SHEETS WERE DISTRIBUTED. ITS ONBOARD RECORDS COULD NOT BE UPDATED UNTIL ITS SECOND APPEARANCE, WHICH WAS ON OUR FINAL WORK DAY. WE WERE ALWAYS BUSY ON THIS DAY TRYING TO MAKE SURE ALL WAS READY FOR THE ONCOMING WORK CREW. IN ADDITION, THE BELL 407 HAS A LARGE AMOUNT OF RECURRING INSPECTIONS WHICH MAKES FOR A COMPLICATED AND MESSY LOOKING MAINT DUE SHEET. AS FOR THE ON-BASE MAINT RECORDS BEING INCORRECT, THIS WAS DONE BY MY OPPOSITES AND I HAVE NO EXPLANATION WHY. THE BACKDATING WAS DUE TO IMPROPER (ACTUALLY NO) TRAINING FOR THE LEAD MECH POS, AND BY THE PRACTICE BEING WINKED AT (UNOFFICIALLY APPROVED OF) BY THOSE WHO WERE MGRS.
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.