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|
Attributes | |
ACN | 523927 |
Time | |
Date | 200109 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : phl.tower |
Make Model Name | B737-200 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 17 |
ASRS Report | 523927 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 19 |
ASRS Report | 523926 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence other |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : repair performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Chart Or Publication |
Primary Problem | Chart Or Publication |
Situations | |
Publication | MAINT. MANUAL PROCEDURE |
Narrative:
I was requested to assist in the removal and reinstallation of a bracket from one aircraft to another. So, I requested paper work and was told by the person I was helping that management was taking care of filling out the job card. Well, the foreman filled out paperwork and lost it, or it was not completed, to replace the bracket on the aircraft. The missing bracket was recovered in heavy maintenance and replaced. So, to prevent this type of event from happening again we must improve on our paper work. Example: have a job card typed and a non-routine card. Callback conversation with reporter revealed the following information: the reporter stated the removed parts procedure is out of hand and has become a serious air safety problem. The reporter said the procedure in place allows a technician to remove a part, as in this case an elevator neutral shift sensor and bracket, with only a supervisor's verbal directive. The reporter stated the supervisor is to initiate the required removed parts form. The reporter said the technician removes the part from the out of service airplane and delivers the part to the technicians working the airplane needing the part. The reporter stated neither the technician removing the part from the out of service airplane, nor the technicians using the part, make any write ups describing the parts transaction. The reporter said all of the documentation is supposed to be done on the supervisor's removed parts form, by the supervisor, which is part of the paperwork package for the airplane being worked. The reporter said the out of service part airplane has no open write-up that a part was removed and was required. The reporter said with three airplanes assigned to each shift supervisor, and each airplane generating approximately 1500 write-ups from the job cards, it's easy for the removed parts form to be overlooked. The reporter stated the last three heavy maintenance checks have had removed parts incidents. Fortunately, someone remembered the removed and not replaced part prior to flight.
Original NASA ASRS Text
Title: TECHNICIANS RPT INADEQUATE COMPANY PROCS TO PREVENT ACFT WITH MISSING OR REMOVED PARTS FROM BEING RETURNED TO SVC.
Narrative: I WAS REQUESTED TO ASSIST IN THE REMOVAL AND REINSTALLATION OF A BRACKET FROM ONE ACFT TO ANOTHER. SO, I REQUESTED PAPER WORK AND WAS TOLD BY THE PERSON I WAS HELPING THAT MGMNT WAS TAKING CARE OF FILLING OUT THE JOB CARD. WELL, THE FOREMAN FILLED OUT PAPERWORK AND LOST IT, OR IT WAS NOT COMPLETED, TO REPLACE THE BRACKET ON THE ACFT. THE MISSING BRACKET WAS RECOVERED IN HEAVY MAINT AND REPLACED. SO, TO PREVENT THIS TYPE OF EVENT FROM HAPPENING AGAIN WE MUST IMPROVE ON OUR PAPER WORK. EXAMPLE: HAVE A JOB CARD TYPED AND A NON-ROUTINE CARD. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE REMOVED PARTS PROC IS OUT OF HAND AND HAS BECOME A SERIOUS AIR SAFETY PROB. THE RPTR SAID THE PROC IN PLACE ALLOWS A TECHNICIAN TO REMOVE A PART, AS IN THIS CASE AN ELEVATOR NEUTRAL SHIFT SENSOR AND BRACKET, WITH ONLY A SUPVR'S VERBAL DIRECTIVE. THE RPTR STATED THE SUPVR IS TO INITIATE THE REQUIRED REMOVED PARTS FORM. THE RPTR SAID THE TECHNICIAN REMOVES THE PART FROM THE OUT OF SVC AIRPLANE AND DELIVERS THE PART TO THE TECHNICIANS WORKING THE AIRPLANE NEEDING THE PART. THE RPTR STATED NEITHER THE TECHNICIAN REMOVING THE PART FROM THE OUT OF SVC AIRPLANE, NOR THE TECHNICIANS USING THE PART, MAKE ANY WRITE UPS DESCRIBING THE PARTS TRANSACTION. THE RPTR SAID ALL OF THE DOCUMENTATION IS SUPPOSED TO BE DONE ON THE SUPVR'S REMOVED PARTS FORM, BY THE SUPVR, WHICH IS PART OF THE PAPERWORK PACKAGE FOR THE AIRPLANE BEING WORKED. THE RPTR SAID THE OUT OF SVC PART AIRPLANE HAS NO OPEN WRITE-UP THAT A PART WAS REMOVED AND WAS REQUIRED. THE RPTR SAID WITH THREE AIRPLANES ASSIGNED TO EACH SHIFT SUPVR, AND EACH AIRPLANE GENERATING APPROX 1500 WRITE-UPS FROM THE JOB CARDS, IT'S EASY FOR THE REMOVED PARTS FORM TO BE OVERLOOKED. THE RPTR STATED THE LAST THREE HEAVY MAINT CHECKS HAVE HAD REMOVED PARTS INCIDENTS. FORTUNATELY, SOMEONE REMEMBERED THE REMOVED AND NOT REPLACED PART PRIOR TO FLT.
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.