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|
Attributes | |
ACN | 470079 |
Time | |
Date | 200004 |
Day | Tue |
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 | |
Controlling Facilities | tower : bos.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
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 : airframe technician : powerplant |
Experience | maintenance technician : 10 |
ASRS Report | 470079 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 13 |
ASRS Report | 470080 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : published procedure non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : briefing performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : repair performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During scheduled maintenance I was assigned, with another mechanic, to change a rudder PCU on a B737-200. It had been changed once already but tested faulty and removed. We were giving the pci job card and extensive turnover sheets with about 7 or 8 shifts of turnovers. The new PCU was ready to be installed when we arrived. We installed it per the maintenance manual and tested it. Part of the test in the maintenance manual says to disconnect the nosewheel steering input rod. Since we were being rushed and the panels were already closed up in the nosewheel well, we installed the nose steering bypass pin instead. The rudder tested ok, inspection checked it out ok and the aircraft was returned to service. During taxi the pilot notified maintenance that he had no rudder pedal nose steering. Maintenance then found that the nose steering rod was disconnected. Turnover sheets were not clear on what has been completed and what still needs to be completed. Also, being that it was a 'C' check, a separate job card to close the nosewheel well was already completed. I think turnover sheets should have open blocks that need to be signed when something is still open, that way an open block will alert us that something is not done and an extra set of eyes checking the paperwork could help.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE RUDDER PEDAL NOSE STEERING INPUT ROD DISCONNECTED.
Narrative: DURING SCHEDULED MAINT I WAS ASSIGNED, WITH ANOTHER MECH, TO CHANGE A RUDDER PCU ON A B737-200. IT HAD BEEN CHANGED ONCE ALREADY BUT TESTED FAULTY AND REMOVED. WE WERE GIVING THE PCI JOB CARD AND EXTENSIVE TURNOVER SHEETS WITH ABOUT 7 OR 8 SHIFTS OF TURNOVERS. THE NEW PCU WAS READY TO BE INSTALLED WHEN WE ARRIVED. WE INSTALLED IT PER THE MAINT MANUAL AND TESTED IT. PART OF THE TEST IN THE MAINT MANUAL SAYS TO DISCONNECT THE NOSEWHEEL STEERING INPUT ROD. SINCE WE WERE BEING RUSHED AND THE PANELS WERE ALREADY CLOSED UP IN THE NOSEWHEEL WELL, WE INSTALLED THE NOSE STEERING BYPASS PIN INSTEAD. THE RUDDER TESTED OK, INSPECTION CHKED IT OUT OK AND THE ACFT WAS RETURNED TO SVC. DURING TAXI THE PLT NOTIFIED MAINT THAT HE HAD NO RUDDER PEDAL NOSE STEERING. MAINT THEN FOUND THAT THE NOSE STEERING ROD WAS DISCONNECTED. TURNOVER SHEETS WERE NOT CLR ON WHAT HAS BEEN COMPLETED AND WHAT STILL NEEDS TO BE COMPLETED. ALSO, BEING THAT IT WAS A 'C' CHK, A SEPARATE JOB CARD TO CLOSE THE NOSEWHEEL WELL WAS ALREADY COMPLETED. I THINK TURNOVER SHEETS SHOULD HAVE OPEN BLOCKS THAT NEED TO BE SIGNED WHEN SOMETHING IS STILL OPEN, THAT WAY AN OPEN BLOCK WILL ALERT US THAT SOMETHING IS NOT DONE AND AN EXTRA SET OF EYES CHKING THE PAPERWORK COULD HELP.
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.