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|
Attributes | |
ACN | 512391 |
Time | |
Date | 200105 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | L-1011 Tri-Star All Series |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : fcc technician : powerplant technician : airframe |
Experience | maintenance avionics : 10 maintenance technician : 10 |
ASRS Report | 512391 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : testing performance deficiency : repair performance deficiency : fault isolation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was assigned to work on air carrier aircraft X, an L1011. The aircraft had an inbound write-up on cabin pressurization. I was familiar with this aircraft and its extensive cabin pressurization history as I had worked it on a previous occasion. The aircraft also had its forward outflow valve on maintenance carryover in accordance with the MEL. After checking the system out, I determined the forward outflow valve actuator to be at fault. I replaced the actuator and, after the appropriate chkout, I signed the item off and released it for service. However, the inbound write-up also addressed improper operation of the cabin altitude warning system. Since I was familiar with the history and was eager to fix the pressurization problem, I failed to fully read and comprehend the significance of the cabin altitude warning system discrepancy and I did nothing to address that aspect of the write-up. The aircraft was dispatched and flew with no discrepancy. The following day, a late night shift lead technician brought this all to my attention. I immediately notified the maintenance coordinator center of my error and had them put a set-up in the operational maintenance instructions to have the cabin altitude warning system checked out.
Original NASA ASRS Text
Title: AN L1011 WAS DISPATCHED IN NON COMPLIANCE WITH AN OPEN LOGBOOK RPT ON THE CABIN ALT WARNING SYS INADVERTENTLY OVERLOOKED.
Narrative: I WAS ASSIGNED TO WORK ON ACR ACFT X, AN L1011. THE ACFT HAD AN INBOUND WRITE-UP ON CABIN PRESSURIZATION. I WAS FAMILIAR WITH THIS ACFT AND ITS EXTENSIVE CABIN PRESSURIZATION HISTORY AS I HAD WORKED IT ON A PREVIOUS OCCASION. THE ACFT ALSO HAD ITS FORWARD OUTFLOW VALVE ON MAINT CARRYOVER IN ACCORDANCE WITH THE MEL. AFTER CHKING THE SYS OUT, I DETERMINED THE FORWARD OUTFLOW VALVE ACTUATOR TO BE AT FAULT. I REPLACED THE ACTUATOR AND, AFTER THE APPROPRIATE CHKOUT, I SIGNED THE ITEM OFF AND RELEASED IT FOR SVC. HOWEVER, THE INBOUND WRITE-UP ALSO ADDRESSED IMPROPER OP OF THE CABIN ALT WARNING SYS. SINCE I WAS FAMILIAR WITH THE HISTORY AND WAS EAGER TO FIX THE PRESSURIZATION PROB, I FAILED TO FULLY READ AND COMPREHEND THE SIGNIFICANCE OF THE CABIN ALT WARNING SYS DISCREPANCY AND I DID NOTHING TO ADDRESS THAT ASPECT OF THE WRITE-UP. THE ACFT WAS DISPATCHED AND FLEW WITH NO DISCREPANCY. THE FOLLOWING DAY, A LATE NIGHT SHIFT LEAD TECHNICIAN BROUGHT THIS ALL TO MY ATTN. I IMMEDIATELY NOTIFIED THE MAINT COORDINATOR CTR OF MY ERROR AND HAD THEM PUT A SET-UP IN THE OPERATIONAL MAINT INSTRUCTIONS TO HAVE THE CABIN ALT WARNING SYS CHKED OUT.
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.