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|
Attributes | |
ACN | 473003 |
Time | |
Date | 200005 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
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 : fcc technician : airframe |
Experience | maintenance lead technician : 10 maintenance technician : 24 |
ASRS Report | 473003 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance avionics : 6 maintenance technician : 15 |
ASRS Report | 473002 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 969 |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals performance deficiency : logbook entry performance deficiency : installation performance deficiency : testing performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Base Maint proc |
Narrative:
Upon accomplishing the rudder pressure reducer and yaw damper coupler installation engineering order. For B737-200, 300, 400 in ZZZ base maintenance, a CAT ii/III status entry in the log book was omitted on all aircraft modified by the base change order crew. It was understood that a work pack entry per base procedure was sufficient to cover all systems affected by the engineering order however, upon further investigation it was noted that there was insufficient paperwork documentation for functional checks on certain systems. Callback conversation with reporter revealed the following information: the reporter stated the engineering order paperwork did not have any directive that required a category ii or autoland test of the autoplt. The reporter said several aircraft were completed before it was discovered that a check was required. The reporter stated that even though the paperwork did not state a check was required, all of the technicians involved should have known the rudder control system was disturbed and a check was needed.
Original NASA ASRS Text
Title: SEVERAL B737 MODELS 200, 300, AND 400 WERE RELEASED FOR SERVICE IN NON COMPLIANCE AFTER A RUDDER CONTROL MODIFICATION WITHOUT CATEGORY II AND AUTOLAND TESTS.
Narrative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
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.