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|
Attributes | |
ACN | 470359 |
Time | |
Date | 200002 |
Day | Fri |
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 : sfb.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 10 |
ASRS Report | 470359 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other other : person 4 |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : investigated other other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : repair performance deficiency : scheduled maintenance performance deficiency : fault isolation performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
This letter is written in regards to aircraft xyz logbook page abcx. On feb/fri/00, I was asked to help in troubleshooting the pack trip problem. During the night it was determined that the bleed overtemp switches for the right system may be faulty. When this determination was made, myself, the other mechanic, and lead WX wxxx went into the shift manager's office to discuss our findings with him and zone X supervisor XXX. The reason for the discussion was the flight information manual called out to flush the right pack heat exchangers but we felt that this was a bleed problem and we should deviate from the flight information manual troubleshooting procedure. In the meeting, all our troubleshooting steps were talked about and the final decision was made with the shift manager and the supervisor to change the 390 and the 490 bleed overtemp switches. This final decision was made at approximately XA00. The other mechanic and myself went to the aircraft parked on ramp and determined that we would not be able to do the job due to the lack of time and that a turnover would be needed. We returned to the shop and proceeded to give a turnover to the next shift lead and zyz xyx. This is the turnover that was given to the next shift. We told them of our meeting and it was determined by all that these 2 switches were in need of change. A logbook entry was made to leak check the switches after their replacement, and the open logbook write-up that switches were being changed for. When we clocked off shift we all felt sure that the items we turned over would be accomplished. When we returned the following shift, we found that the switches were not replaced, making the write-up we entered invalid. The only reason for making an entry for leak and operations checking the 390-490 switches was that in our turnover we told the next shift that these switches needed to be changed, and we were assured that these items would be changed.
Original NASA ASRS Text
Title: A B737-700 WAS DISPATCHED IN NON COMPLIANCE WITH A LOGBOOK ENTRY FOR LEAK TESTING BLEED SENSORS THAT WERE NOT INSTALLED.
Narrative: THIS LETTER IS WRITTEN IN REGARDS TO ACFT XYZ LOGBOOK PAGE ABCX. ON FEB/FRI/00, I WAS ASKED TO HELP IN TROUBLESHOOTING THE PACK TRIP PROB. DURING THE NIGHT IT WAS DETERMINED THAT THE BLEED OVERTEMP SWITCHES FOR THE R SYS MAY BE FAULTY. WHEN THIS DETERMINATION WAS MADE, MYSELF, THE OTHER MECH, AND LEAD WX WXXX WENT INTO THE SHIFT MGR'S OFFICE TO DISCUSS OUR FINDINGS WITH HIM AND ZONE X SUPVR XXX. THE REASON FOR THE DISCUSSION WAS THE FLT INFO MANUAL CALLED OUT TO FLUSH THE R PACK HEAT EXCHANGERS BUT WE FELT THAT THIS WAS A BLEED PROB AND WE SHOULD DEVIATE FROM THE FLT INFO MANUAL TROUBLESHOOTING PROC. IN THE MEETING, ALL OUR TROUBLESHOOTING STEPS WERE TALKED ABOUT AND THE FINAL DECISION WAS MADE WITH THE SHIFT MGR AND THE SUPVR TO CHANGE THE 390 AND THE 490 BLEED OVERTEMP SWITCHES. THIS FINAL DECISION WAS MADE AT APPROX XA00. THE OTHER MECH AND MYSELF WENT TO THE ACFT PARKED ON RAMP AND DETERMINED THAT WE WOULD NOT BE ABLE TO DO THE JOB DUE TO THE LACK OF TIME AND THAT A TURNOVER WOULD BE NEEDED. WE RETURNED TO THE SHOP AND PROCEEDED TO GIVE A TURNOVER TO THE NEXT SHIFT LEAD AND ZYZ XYX. THIS IS THE TURNOVER THAT WAS GIVEN TO THE NEXT SHIFT. WE TOLD THEM OF OUR MEETING AND IT WAS DETERMINED BY ALL THAT THESE 2 SWITCHES WERE IN NEED OF CHANGE. A LOGBOOK ENTRY WAS MADE TO LEAK CHK THE SWITCHES AFTER THEIR REPLACEMENT, AND THE OPEN LOGBOOK WRITE-UP THAT SWITCHES WERE BEING CHANGED FOR. WHEN WE CLOCKED OFF SHIFT WE ALL FELT SURE THAT THE ITEMS WE TURNED OVER WOULD BE ACCOMPLISHED. WHEN WE RETURNED THE FOLLOWING SHIFT, WE FOUND THAT THE SWITCHES WERE NOT REPLACED, MAKING THE WRITE-UP WE ENTERED INVALID. THE ONLY REASON FOR MAKING AN ENTRY FOR LEAK AND OPS CHKING THE 390-490 SWITCHES WAS THAT IN OUR TURNOVER WE TOLD THE NEXT SHIFT THAT THESE SWITCHES NEEDED TO BE CHANGED, AND WE WERE ASSURED THAT THESE ITEMS WOULD BE CHANGED.
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.