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|
Attributes | |
ACN | 480268 |
Time | |
Date | 200007 |
Day | Mon |
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 | B737-300 |
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 : 20 |
ASRS Report | 480268 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : work cards performance deficiency : installation performance deficiency : logbook entry performance deficiency : repair performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
While working a turnover job from previous shift on engineering order wvwx, revision a, aircraft xyz, it was noted that all wires had been run to proper location and ground wires needed dual grounds and installed to aircraft grounds. Seeing that a single wire was hanging, I terminated that wire with dual ground and installed it. Due to the time (XA30) I notified my lead and next shift lead of the problem of wires terminating at wrong grounds and it was stated that a turnover should be written on write-up noting the problem, and he would notify supervisor for need of engineering authority/authorized to cover the misrouted wires. I signed the turnover stating wire ground was not the terminating ground for wire and it had been installed incorrectly. I later found out that the engineering authority/authorized had been issued after aircraft xyz had departed ZZZ maintenance check and was grounded until problem was corrected. Callback conversation with reporter revealed the following information: the reporter stated all of the information on the incorrect ground wiring termination was passed on by a non routine write-up and verbally to the lead supervisor and local engineering. The reporter said the failure occurred at the engineering level where the engineering authority/authorized requirement was missed and not noticed until the aircraft was released for service and departed.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH INCORRECT GND FUELING VALVE WIRING TERMINATION.
Narrative: WHILE WORKING A TURNOVER JOB FROM PREVIOUS SHIFT ON ENGINEERING ORDER WVWX, REVISION A, ACFT XYZ, IT WAS NOTED THAT ALL WIRES HAD BEEN RUN TO PROPER LOCATION AND GND WIRES NEEDED DUAL GNDS AND INSTALLED TO ACFT GNDS. SEEING THAT A SINGLE WIRE WAS HANGING, I TERMINATED THAT WIRE WITH DUAL GND AND INSTALLED IT. DUE TO THE TIME (XA30) I NOTIFIED MY LEAD AND NEXT SHIFT LEAD OF THE PROB OF WIRES TERMINATING AT WRONG GNDS AND IT WAS STATED THAT A TURNOVER SHOULD BE WRITTEN ON WRITE-UP NOTING THE PROB, AND HE WOULD NOTIFY SUPVR FOR NEED OF ENGINEERING AUTH TO COVER THE MISROUTED WIRES. I SIGNED THE TURNOVER STATING WIRE GND WAS NOT THE TERMINATING GND FOR WIRE AND IT HAD BEEN INSTALLED INCORRECTLY. I LATER FOUND OUT THAT THE ENGINEERING AUTH HAD BEEN ISSUED AFTER ACFT XYZ HAD DEPARTED ZZZ MAINT CHK AND WAS GNDED UNTIL PROB WAS CORRECTED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED ALL OF THE INFO ON THE INCORRECT GND WIRING TERMINATION WAS PASSED ON BY A NON ROUTINE WRITE-UP AND VERBALLY TO THE LEAD SUPVR AND LCL ENGINEERING. THE RPTR SAID THE FAILURE OCCURRED AT THE ENGINEERING LEVEL WHERE THE ENGINEERING AUTH REQUIREMENT WAS MISSED AND NOT NOTICED UNTIL THE ACFT WAS RELEASED FOR SVC AND DEPARTED.
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.