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|
Attributes | |
ACN | 505571 |
Time | |
Date | 200103 |
Day | Thu |
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 : ord.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 27l |
Flight Phase | descent : approach ground : parked ground : maintenance |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | pilot : atp technician : powerplant technician : airframe technician : inspection authority |
Experience | maintenance technician : 13 |
ASRS Report | 505571 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer maintenance : technician |
Qualification | pilot : instrument pilot : commercial pilot : multi engine technician : fcc technician : powerplant technician : airframe |
Experience | maintenance technician : 16 |
ASRS Report | 504987 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | atc equipment other atc equipment : radar aircraft equipment other aircraft equipment : glideslope other controllera other flight crewa other other : person 3 |
Resolutory Action | controller : issued advisory flight crew : returned to original clearance flight crew : overrode automation flight crew : took precautionary avoidance action none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication ATC Facility |
Primary Problem | ATC Facility |
Situations | |
Publication | MAINT PROCS |
Narrative:
This letter is to inform other inspectors of a situation that occurred on mar/xa/01 in ZZZ heavy maintenance. I was working an air carrier aircraft that had a 178 bulkhead engineering order to be accomplished. On the engineering order there was a block for a mechanic to install cable blocks for the stabilizer cables. I took my torque seal out and installed on the able blocks, verifying no slippage. Thinking the intent of my job was complete, because the mechanic had the 'do not operate' tag ready to be installed. I stamped the 'checked by' block as completed. Unknowingly, the current special procedures manual and manual states that cables are to be blocked and torque sealed and 'do not operate' tags installed and labeled at which body station they were installed at the blocks and in the cockpit for the appropriate system and a fluorescent streamer installed. Since the engineering order had a block for the installation of cable blocks for the stabilizer control cables, and knowing the mechanic did good work in the past, I was complacent and did not verify he wrote the body station on the 'do not operate' tag or on the engineering order. Either one of which would have been in compliance with the special procedures manual. A courtesy and safety function we should have provided to the next inspector and mechanic working the job.
Original NASA ASRS Text
Title: DURING HVY MAINT AN FAA INSPECTOR OBSERVED MAINT PROCS FOR BLOCKING AND DOCUMENTING CTL CABLES WERE NOT FOLLOWED.
Narrative: THIS LETTER IS TO INFORM OTHER INSPECTORS OF A SIT THAT OCCURRED ON MAR/XA/01 IN ZZZ HVY MAINT. I WAS WORKING AN ACR ACFT THAT HAD A 178 BULKHEAD ENGINEERING ORDER TO BE ACCOMPLISHED. ON THE ENGINEERING ORDER THERE WAS A BLOCK FOR A MECH TO INSTALL CABLE BLOCKS FOR THE STABILIZER CABLES. I TOOK MY TORQUE SEAL OUT AND INSTALLED ON THE ABLE BLOCKS, VERIFYING NO SLIPPAGE. THINKING THE INTENT OF MY JOB WAS COMPLETE, BECAUSE THE MECH HAD THE 'DO NOT OPERATE' TAG READY TO BE INSTALLED. I STAMPED THE 'CHKED BY' BLOCK AS COMPLETED. UNKNOWINGLY, THE CURRENT SPECIAL PROCS MANUAL AND MANUAL STATES THAT CABLES ARE TO BE BLOCKED AND TORQUE SEALED AND 'DO NOT OPERATE' TAGS INSTALLED AND LABELED AT WHICH BODY STATION THEY WERE INSTALLED AT THE BLOCKS AND IN THE COCKPIT FOR THE APPROPRIATE SYS AND A FLUORESCENT STREAMER INSTALLED. SINCE THE ENGINEERING ORDER HAD A BLOCK FOR THE INSTALLATION OF CABLE BLOCKS FOR THE STABILIZER CTL CABLES, AND KNOWING THE MECH DID GOOD WORK IN THE PAST, I WAS COMPLACENT AND DID NOT VERIFY HE WROTE THE BODY STATION ON THE 'DO NOT OPERATE' TAG OR ON THE ENGINEERING ORDER. EITHER ONE OF WHICH WOULD HAVE BEEN IN COMPLIANCE WITH THE SPECIAL PROCS MANUAL. A COURTESY AND SAFETY FUNCTION WE SHOULD HAVE PROVIDED TO THE NEXT INSPECTOR AND MECH WORKING THE JOB.
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.