37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 487281 |
Time | |
Date | 200009 |
Day | Sat |
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 | MD-80 Series (DC-9-80) 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 : airframe technician : fcc technician : powerplant |
Experience | maintenance avionics : 4 maintenance lead technician : 3 maintenance technician : 12 |
ASRS Report | 487281 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 969 |
Consequence | other |
Factors | |
Maintenance | performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On sep/sat/00, I was given aircraft xyz to work on. Previous shift maintenance had replaced the EPR transmitter for a throttle split problem and had accomplished an overnight check. The EPR transmitter was installed but needed an 'O' ring on the sense line. My partner installed the 'O' ring and verified that the new part was installed. I took the aircraft to the run-up area and ran the engine at the power setting as per the maintenance manual. Everything checked out and I delivered the aircraft to the gate. There was no sign off for the installation of the part, so I had to sign for the removal and replacement of the EPR transmitter which I was not happy about. There was no mention of initiating a follow-up in the logbook. All of the open items on the log page were signed off so I signed off the airworthiness. Unknown to me, there was a follow-up requirement for MEL 27-14 that had to be done on the overnight that was not done. I did not check the MEL sticker on the logbook cover, but I assumed that the MEL was continued on previous shift. The crew took the plane and flew a couple of legs until the discrepancy was noticed in XXX. XXX complied with the follow-up and notified ZZZ maintenance who in turn notified me. I did not investigate the MEL on the aircraft before signing the aircraft airworthiness, but assumed that the previous shift had addressed whatever maintenance was required whether it was working on the system or deferring it.
Original NASA ASRS Text
Title: AN MD88 WAS DISPATCHED IN NON COMPLIANCE WITH A DEFERRED ELEVATOR PWR ON INDICATING SYS OUT OF TIME LIMITS, DUE TO CARELESS PAPERWORK MGMNT.
Narrative: ON SEP/SAT/00, I WAS GIVEN ACFT XYZ TO WORK ON. PREVIOUS SHIFT MAINT HAD REPLACED THE EPR XMITTER FOR A THROTTLE SPLIT PROB AND HAD ACCOMPLISHED AN OVERNIGHT CHK. THE EPR XMITTER WAS INSTALLED BUT NEEDED AN 'O' RING ON THE SENSE LINE. MY PARTNER INSTALLED THE 'O' RING AND VERIFIED THAT THE NEW PART WAS INSTALLED. I TOOK THE ACFT TO THE RUN-UP AREA AND RAN THE ENG AT THE PWR SETTING AS PER THE MAINT MANUAL. EVERYTHING CHKED OUT AND I DELIVERED THE ACFT TO THE GATE. THERE WAS NO SIGN OFF FOR THE INSTALLATION OF THE PART, SO I HAD TO SIGN FOR THE REMOVAL AND REPLACEMENT OF THE EPR XMITTER WHICH I WAS NOT HAPPY ABOUT. THERE WAS NO MENTION OF INITIATING A FOLLOW-UP IN THE LOGBOOK. ALL OF THE OPEN ITEMS ON THE LOG PAGE WERE SIGNED OFF SO I SIGNED OFF THE AIRWORTHINESS. UNKNOWN TO ME, THERE WAS A FOLLOW-UP REQUIREMENT FOR MEL 27-14 THAT HAD TO BE DONE ON THE OVERNIGHT THAT WAS NOT DONE. I DID NOT CHK THE MEL STICKER ON THE LOGBOOK COVER, BUT I ASSUMED THAT THE MEL WAS CONTINUED ON PREVIOUS SHIFT. THE CREW TOOK THE PLANE AND FLEW A COUPLE OF LEGS UNTIL THE DISCREPANCY WAS NOTICED IN XXX. XXX COMPLIED WITH THE FOLLOW-UP AND NOTIFIED ZZZ MAINT WHO IN TURN NOTIFIED ME. I DID NOT INVESTIGATE THE MEL ON THE ACFT BEFORE SIGNING THE ACFT AIRWORTHINESS, BUT ASSUMED THAT THE PREVIOUS SHIFT HAD ADDRESSED WHATEVER MAINT WAS REQUIRED WHETHER IT WAS WORKING ON THE SYS OR DEFERRING IT.
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.