Narrative:

Air carrier (ZZZ, us) hangar Z check, bay X aircraft #xyz. Pretest flight inspection task card yxyx was issued. I signed off blocks stating all cards accounted for and all cards reviewed. Aircraft deemed satisfactory for test flight. Work card wxxx-XXXW was lost at the time and not cleared. The mistake was discovered upon review of the cards at the end of the Z check. Card wxxx-XXXW was written to cover aircraft elevator cable disconnect. The cables were reconnected and safetied. The card was not completed. Supplemental information from acn 482037: the foreman, myself, and planning talked about the card being lost. I was informed that the aircraft had 2 test flts and that all other cards were closed, so I said 'I'll verify that the elevator pulleys were installed and that the cable blocks were removed.' I then checked the bulkhead. Checked cables by hand, looked at safeties on cables -- all ok, and signed card off. Later the next day, the card (original) was found on tail dock and it stated that cable tensions were not up to maintenance manual tension. Aircraft was stopped and tension brought up to maintenance manual standards. I felt when I signed card off there was no safety of flight going by what was written as the discrepancy. I feel like I never should have dealt with this card, since it should have been taken care of between the 2 test flts when done. Supplemental information from acn 483143: before the first test flight, the tracking duplicate for this write-up was located in the duplicate box, indicating the write-up had been completed and was either in the hands of inspection or production foreman for final signoffs. I then issued a pre test flight card to the inspectors assigned to bay X. A facts database list of all routine and non routine items remaining open on this aircraft. The aircraft failed this first test flight due to a manual reversion anomaly and a fluttering spoiler. These discrepancies, along with additional non airworthy logbook and non routine write-ups, were worked on until saturday. A second pre test flight card was issued to inspection, again with a facts database printout of all open routine and non routine items attached to the card. The tracking duplicate was still in the duplicate box and no one recognized the write-up as missing, or unaccounted for. The aircraft made its second test flight on aug/sat/00 and passed the manual reversion test. A new hire controller, replacing one who quit, was in the initial training stage during the check. There are 2 new foremen in the bay working their first Z check on their own and are not familiar with policies, procedures, or handling of paperwork according to the program. To get the aircraft out and run and ready for test flight put everyone in a rush to clear the airworthy items and get the aircraft in the air. Problem began with the failure of the mechanic and lead assigned the card to ensure its return to the production work center at the end of the shift. Followed by the failure of the production controllers to maintain control of the outstanding documents while in the closeout phase of the check. In the end, the failure of the production foreman and inspector who signed off the reprinted document to do a tension check of the cables rather than a visual check before releasing the aircraft.

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Original NASA ASRS Text

Title: A B737-300 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH INCOMPLETE AND MISSING DOCUMENTATION ON THE ELEVATOR CTL SYS.

Narrative: ACR (ZZZ, US) HANGAR Z CHK, BAY X ACFT #XYZ. PRETEST FLT INSPECTION TASK CARD YXYX WAS ISSUED. I SIGNED OFF BLOCKS STATING ALL CARDS ACCOUNTED FOR AND ALL CARDS REVIEWED. ACFT DEEMED SATISFACTORY FOR TEST FLT. WORK CARD WXXX-XXXW WAS LOST AT THE TIME AND NOT CLRED. THE MISTAKE WAS DISCOVERED UPON REVIEW OF THE CARDS AT THE END OF THE Z CHK. CARD WXXX-XXXW WAS WRITTEN TO COVER ACFT ELEVATOR CABLE DISCONNECT. THE CABLES WERE RECONNECTED AND SAFETIED. THE CARD WAS NOT COMPLETED. SUPPLEMENTAL INFO FROM ACN 482037: THE FOREMAN, MYSELF, AND PLANNING TALKED ABOUT THE CARD BEING LOST. I WAS INFORMED THAT THE ACFT HAD 2 TEST FLTS AND THAT ALL OTHER CARDS WERE CLOSED, SO I SAID 'I'LL VERIFY THAT THE ELEVATOR PULLEYS WERE INSTALLED AND THAT THE CABLE BLOCKS WERE REMOVED.' I THEN CHKED THE BULKHEAD. CHKED CABLES BY HAND, LOOKED AT SAFETIES ON CABLES -- ALL OK, AND SIGNED CARD OFF. LATER THE NEXT DAY, THE CARD (ORIGINAL) WAS FOUND ON TAIL DOCK AND IT STATED THAT CABLE TENSIONS WERE NOT UP TO MAINT MANUAL TENSION. ACFT WAS STOPPED AND TENSION BROUGHT UP TO MAINT MANUAL STANDARDS. I FELT WHEN I SIGNED CARD OFF THERE WAS NO SAFETY OF FLT GOING BY WHAT WAS WRITTEN AS THE DISCREPANCY. I FEEL LIKE I NEVER SHOULD HAVE DEALT WITH THIS CARD, SINCE IT SHOULD HAVE BEEN TAKEN CARE OF BTWN THE 2 TEST FLTS WHEN DONE. SUPPLEMENTAL INFO FROM ACN 483143: BEFORE THE FIRST TEST FLT, THE TRACKING DUPLICATE FOR THIS WRITE-UP WAS LOCATED IN THE DUPLICATE BOX, INDICATING THE WRITE-UP HAD BEEN COMPLETED AND WAS EITHER IN THE HANDS OF INSPECTION OR PRODUCTION FOREMAN FOR FINAL SIGNOFFS. I THEN ISSUED A PRE TEST FLT CARD TO THE INSPECTORS ASSIGNED TO BAY X. A FACTS DATABASE LIST OF ALL ROUTINE AND NON ROUTINE ITEMS REMAINING OPEN ON THIS ACFT. THE ACFT FAILED THIS FIRST TEST FLT DUE TO A MANUAL REVERSION ANOMALY AND A FLUTTERING SPOILER. THESE DISCREPANCIES, ALONG WITH ADDITIONAL NON AIRWORTHY LOGBOOK AND NON ROUTINE WRITE-UPS, WERE WORKED ON UNTIL SATURDAY. A SECOND PRE TEST FLT CARD WAS ISSUED TO INSPECTION, AGAIN WITH A FACTS DATABASE PRINTOUT OF ALL OPEN ROUTINE AND NON ROUTINE ITEMS ATTACHED TO THE CARD. THE TRACKING DUPLICATE WAS STILL IN THE DUPLICATE BOX AND NO ONE RECOGNIZED THE WRITE-UP AS MISSING, OR UNACCOUNTED FOR. THE ACFT MADE ITS SECOND TEST FLT ON AUG/SAT/00 AND PASSED THE MANUAL REVERSION TEST. A NEW HIRE CTLR, REPLACING ONE WHO QUIT, WAS IN THE INITIAL TRAINING STAGE DURING THE CHK. THERE ARE 2 NEW FOREMEN IN THE BAY WORKING THEIR FIRST Z CHK ON THEIR OWN AND ARE NOT FAMILIAR WITH POLICIES, PROCS, OR HANDLING OF PAPERWORK ACCORDING TO THE PROGRAM. TO GET THE ACFT OUT AND RUN AND READY FOR TEST FLT PUT EVERYONE IN A RUSH TO CLR THE AIRWORTHY ITEMS AND GET THE ACFT IN THE AIR. PROB BEGAN WITH THE FAILURE OF THE MECH AND LEAD ASSIGNED THE CARD TO ENSURE ITS RETURN TO THE PRODUCTION WORK CTR AT THE END OF THE SHIFT. FOLLOWED BY THE FAILURE OF THE PRODUCTION CTLRS TO MAINTAIN CTL OF THE OUTSTANDING DOCUMENTS WHILE IN THE CLOSEOUT PHASE OF THE CHK. IN THE END, THE FAILURE OF THE PRODUCTION FOREMAN AND INSPECTOR WHO SIGNED OFF THE REPRINTED DOCUMENT TO DO A TENSION CHK OF THE CABLES RATHER THAN A VISUAL CHK BEFORE RELEASING THE ACFT.

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.