37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 460031 |
Time | |
Date | 200001 |
Day | Thu |
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 | Fokker 100 |
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 : 20 |
ASRS Report | 460031 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : published procedure |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : fault isolation performance deficiency : installation performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft xyz came to gate with flare light extended. I mistook the flare light for the taxi light. I installed a taxi light in the flare light position. I did not connect cannon plug due to lack of time and having to open radome for access. I secured the cannon plug so it would not be loose in the radome area. I MEL'ed the taxi light MEL reference 33-41-1A, the same MEL for flare light. I pulled and collared the circuit breaker for taxi light. Upon entering the parts into the computer, I realized that the part numbers were different. I researched the maintenance manual and found my mistake. I notified air carrier maintenance control and they said they would notify abc to correct the light assemblies at the aircraft's next destination. Aircraft was flying from clt to abc on flight XXX and then overnighting in abc. Error could have been corrected by 1) reading maintenance manual closer and paying better attention to drawing, 2) labeling flight switches in cockpit -- can't be seen from standing in cockpit, switches hide labels. I also followed up on this by personally contacting abc maintenance. Followed up on jan/xa/00 to make sure light assembly had been changed and situation corrected. Maintenance manual shows picture of which light is which, but it is not written in the work procedures. Ipc doesn't show the difference of these 2 light assemblies.
Original NASA ASRS Text
Title: A FOKKER 100 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT LAMP INADVERTENTLY INSTALLED IN A LNDG LIGHT POS.
Narrative: ACFT XYZ CAME TO GATE WITH FLARE LIGHT EXTENDED. I MISTOOK THE FLARE LIGHT FOR THE TAXI LIGHT. I INSTALLED A TAXI LIGHT IN THE FLARE LIGHT POS. I DID NOT CONNECT CANNON PLUG DUE TO LACK OF TIME AND HAVING TO OPEN RADOME FOR ACCESS. I SECURED THE CANNON PLUG SO IT WOULD NOT BE LOOSE IN THE RADOME AREA. I MEL'ED THE TAXI LIGHT MEL REF 33-41-1A, THE SAME MEL FOR FLARE LIGHT. I PULLED AND COLLARED THE CIRCUIT BREAKER FOR TAXI LIGHT. UPON ENTERING THE PARTS INTO THE COMPUTER, I REALIZED THAT THE PART NUMBERS WERE DIFFERENT. I RESEARCHED THE MAINT MANUAL AND FOUND MY MISTAKE. I NOTIFIED ACR MAINT CTL AND THEY SAID THEY WOULD NOTIFY ABC TO CORRECT THE LIGHT ASSEMBLIES AT THE ACFT'S NEXT DEST. ACFT WAS FLYING FROM CLT TO ABC ON FLT XXX AND THEN OVERNIGHTING IN ABC. ERROR COULD HAVE BEEN CORRECTED BY 1) READING MAINT MANUAL CLOSER AND PAYING BETTER ATTN TO DRAWING, 2) LABELING FLT SWITCHES IN COCKPIT -- CAN'T BE SEEN FROM STANDING IN COCKPIT, SWITCHES HIDE LABELS. I ALSO FOLLOWED UP ON THIS BY PERSONALLY CONTACTING ABC MAINT. FOLLOWED UP ON JAN/XA/00 TO MAKE SURE LIGHT ASSEMBLY HAD BEEN CHANGED AND SIT CORRECTED. MAINT MANUAL SHOWS PICTURE OF WHICH LIGHT IS WHICH, BUT IT IS NOT WRITTEN IN THE WORK PROCS. IPC DOESN'T SHOW THE DIFFERENCE OF THESE 2 LIGHT ASSEMBLIES.
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.