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|
Attributes | |
ACN | 482379 |
Time | |
Date | 200008 |
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 : mdsd.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority technician : airframe technician : powerplant |
Experience | maintenance technician : 25 |
ASRS Report | 482379 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Situations | |
Publication | B737-RUDDER POWER UNIT MM |
Narrative:
At beginning of shift turnover from previous shift, I received an incomplete work package. The previous shift had signed off the tail section for work and inspection complete. However, when I examined the paperwork on the block for rudder PCU installation, operations check and final operations check, this section had not been signed off. The above aircraft panels (access) were closed to that area. Apparently no inspection had been done. I informed my supervisor mr vyu wxxx who I think stamped or signed this section off. I just went through an earlier similar situation with air carrier #xyz about a month ago which I did report to your office. This situation has not yet been corrected and still remains a valid argument with administration and maintenance. Callback conversation with reporter revealed the following information: the reporter stated the same job cards that allowed a B737-300 to be released into service with incorrect hydraulic line connections almost allowed a rudder power unit to be released with no installation inspection. The reporter said the vertical stabilizer was closed up and the final inspection card was signed off when it was discovered the rudder power unit installation and test inspection was not signed. The reporter stated that he refused to sign for the inspection unless the vertical stabilizer access panel was opened to inspect the installation. The reporter said the job cards which cause this problem need revision, but the company is resisting any change. The vertical stabilizer was opened and the inspection supervisor signed for the installation inspection.
Original NASA ASRS Text
Title: A B737-200 AFTER RUDDER PWR UNIT REPLACEMENT THE VERT STABILIZER WAS CLOSED PRIOR TO FINAL INSPECTION. FINAL INSPECTION SIGNED OFF BY INSPECTION SUPVR.
Narrative: AT BEGINNING OF SHIFT TURNOVER FROM PREVIOUS SHIFT, I RECEIVED AN INCOMPLETE WORK PACKAGE. THE PREVIOUS SHIFT HAD SIGNED OFF THE TAIL SECTION FOR WORK AND INSPECTION COMPLETE. HOWEVER, WHEN I EXAMINED THE PAPERWORK ON THE BLOCK FOR RUDDER PCU INSTALLATION, OPS CHK AND FINAL OPS CHK, THIS SECTION HAD NOT BEEN SIGNED OFF. THE ABOVE ACFT PANELS (ACCESS) WERE CLOSED TO THAT AREA. APPARENTLY NO INSPECTION HAD BEEN DONE. I INFORMED MY SUPVR MR VYU WXXX WHO I THINK STAMPED OR SIGNED THIS SECTION OFF. I JUST WENT THROUGH AN EARLIER SIMILAR SIT WITH ACR #XYZ ABOUT A MONTH AGO WHICH I DID RPT TO YOUR OFFICE. THIS SIT HAS NOT YET BEEN CORRECTED AND STILL REMAINS A VALID ARGUMENT WITH ADMINISTRATION AND MAINT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE SAME JOB CARDS THAT ALLOWED A B737-300 TO BE RELEASED INTO SVC WITH INCORRECT HYD LINE CONNECTIONS ALMOST ALLOWED A RUDDER PWR UNIT TO BE RELEASED WITH NO INSTALLATION INSPECTION. THE RPTR SAID THE VERT STABILIZER WAS CLOSED UP AND THE FINAL INSPECTION CARD WAS SIGNED OFF WHEN IT WAS DISCOVERED THE RUDDER PWR UNIT INSTALLATION AND TEST INSPECTION WAS NOT SIGNED. THE RPTR STATED THAT HE REFUSED TO SIGN FOR THE INSPECTION UNLESS THE VERT STABILIZER ACCESS PANEL WAS OPENED TO INSPECT THE INSTALLATION. THE RPTR SAID THE JOB CARDS WHICH CAUSE THIS PROB NEED REVISION, BUT THE COMPANY IS RESISTING ANY CHANGE. THE VERT STABILIZER WAS OPENED AND THE INSPECTION SUPVR SIGNED FOR THE INSTALLATION INSPECTION.
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.