37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 518649 |
Time | |
Date | 200107 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : ord.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-200 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe |
Experience | maintenance lead technician : 2 maintenance technician : 12.5 |
ASRS Report | 518649 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation 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 | faa : investigated other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : training performance deficiency : unqualified personnel performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
While working a structure repair on a B767-200 while under a c-chk at base maintenance, observed group of flight cables bunched together by a zip-tie at 2 locations. My foreman asked me to remove them if not properly documented. I removed them after I verified they were improperly installed. I returned the next shift to work to find the same zip-ties installed improperly. I immediately told my foreman that I would document the zip-ties properly. I viewed the standard practice manual which had no set procedure for 'zip-ties.' after consulting my work partner, inspection as well as the inspection foreman, we or I rather chose to follow the procedures for a similar job of cable blocking. Since I was not taking tension of the cable or actually installing blocks requiring slippage marks or torque sealing. I felt I only needed to document location of zip-ties and attach red streamer to them. When in reality I should have attached a form XXX to zip-ties, work card, and controls affected in cockpit. The FAA found the zip-ties improperly installed during a routine walk-through prior to the close up of this work area (floorboards still removed). The cable blocking reference does not tell me to fill out XXX for zip-ties. Only cable blocks when you look up procedures for installing a form XXX it does tell you to use when 'tying back' cables or affecting cable subassemblies.
Original NASA ASRS Text
Title: A B767-200 DURING HVY MAINT THE FAA SAFETY INSPECTOR DISCOVERED FLT CTL CABLES BLOCKED WITH UNAPPROVED 'TIE WRAPS' AND NO DOCUMENTATION.
Narrative: WHILE WORKING A STRUCTURE REPAIR ON A B767-200 WHILE UNDER A C-CHK AT BASE MAINT, OBSERVED GROUP OF FLT CABLES BUNCHED TOGETHER BY A ZIP-TIE AT 2 LOCATIONS. MY FOREMAN ASKED ME TO REMOVE THEM IF NOT PROPERLY DOCUMENTED. I REMOVED THEM AFTER I VERIFIED THEY WERE IMPROPERLY INSTALLED. I RETURNED THE NEXT SHIFT TO WORK TO FIND THE SAME ZIP-TIES INSTALLED IMPROPERLY. I IMMEDIATELY TOLD MY FOREMAN THAT I WOULD DOCUMENT THE ZIP-TIES PROPERLY. I VIEWED THE STANDARD PRACTICE MANUAL WHICH HAD NO SET PROC FOR 'ZIP-TIES.' AFTER CONSULTING MY WORK PARTNER, INSPECTION AS WELL AS THE INSPECTION FOREMAN, WE OR I RATHER CHOSE TO FOLLOW THE PROCS FOR A SIMILAR JOB OF CABLE BLOCKING. SINCE I WAS NOT TAKING TENSION OF THE CABLE OR ACTUALLY INSTALLING BLOCKS REQUIRING SLIPPAGE MARKS OR TORQUE SEALING. I FELT I ONLY NEEDED TO DOCUMENT LOCATION OF ZIP-TIES AND ATTACH RED STREAMER TO THEM. WHEN IN REALITY I SHOULD HAVE ATTACHED A FORM XXX TO ZIP-TIES, WORK CARD, AND CTLS AFFECTED IN COCKPIT. THE FAA FOUND THE ZIP-TIES IMPROPERLY INSTALLED DURING A ROUTINE WALK-THROUGH PRIOR TO THE CLOSE UP OF THIS WORK AREA (FLOORBOARDS STILL REMOVED). THE CABLE BLOCKING REF DOES NOT TELL ME TO FILL OUT XXX FOR ZIP-TIES. ONLY CABLE BLOCKS WHEN YOU LOOK UP PROCS FOR INSTALLING A FORM XXX IT DOES TELL YOU TO USE WHEN 'TYING BACK' CABLES OR AFFECTING CABLE SUBASSEMBLIES.
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.