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|
Attributes | |
ACN | 524911 |
Time | |
Date | 200109 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
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 | Fokker 100 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 1 maintenance technician : 12 |
ASRS Report | 524911 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was a lead mechanic on june/thu/01 on aircraft X in for a 'C' check. A mechanic on my crew was assigned to replace a cracked angle on the pressure (aft) bulkhead. He was working off of a job card and a job card turnover sheet. When it was time to install the new part, he made me aware of the fact that to install the angle with solid fasteners he would have to remove components for access. I went to the 2ND shift engineer on duty and asked for authorization to install cherry maximum fasteners. He said that we could not use cherry maximum for that angle. I then informed my direct supervisor of the situation. He informed me to stop the job until he did some research. He returned later and instructed us to install the angle with cherry maximum fasteners. The mechanic did this and short signed the job card as installed cherry maximum fasteners per supervisors instruction. On sep/tue/01 the aircraft was brought in for repetitive inspection and the angel was reworked installing the correct fasteners. On sep/mon/01 the airlines quality and assurance department contacted me to question my knowledge and recollection of that job. They informed me that I failed to see the added directive number on the job card and that the directive should have been with the work pack. The directive called out an engineering authority that specified the fasteners that were to be installed. If this paperwork had been with the pack there would have been no question as to how to install the part. Also north speaking with quality and assurance and the FAA rep I now know that following verbal instruction is not a correct sign off.
Original NASA ASRS Text
Title: A FOKKER 100 WAS DISCOVERED TO HAVE A REPAIR TO THE AFT PRESSURE DOME ACCOMPLISHED USING SUBSTITUTE FASTENERS WITH NO DOCUMENTATION.
Narrative: I WAS A LEAD MECHANIC ON JUNE/THU/01 ON ACFT X IN FOR A 'C' CHECK. A MECHANIC ON MY CREW WAS ASSIGNED TO REPLACE A CRACKED ANGLE ON THE PRESSURE (AFT) BULKHEAD. HE WAS WORKING OFF OF A JOB CARD AND A JOB CARD TURNOVER SHEET. WHEN IT WAS TIME TO INSTALL THE NEW PART, HE MADE ME AWARE OF THE FACT THAT TO INSTALL THE ANGLE WITH SOLID FASTENERS HE WOULD HAVE TO REMOVE COMPONENTS FOR ACCESS. I WENT TO THE 2ND SHIFT ENGINEER ON DUTY AND ASKED FOR AUTHORIZATION TO INSTALL CHERRY MAX FASTENERS. HE SAID THAT WE COULD NOT USE CHERRY MAX FOR THAT ANGLE. I THEN INFORMED MY DIRECT SUPERVISOR OF THE SIT. HE INFORMED ME TO STOP THE JOB UNTIL HE DID SOME RESEARCH. HE RETURNED LATER AND INSTRUCTED US TO INSTALL THE ANGLE WITH CHERRY MAX FASTENERS. THE MECHANIC DID THIS AND SHORT SIGNED THE JOB CARD AS INSTALLED CHERRY MAX FASTENERS PER SUPERVISORS INSTRUCTION. ON SEP/TUE/01 THE ACFT WAS BROUGHT IN FOR REPETITIVE INSPECTION AND THE ANGEL WAS REWORKED INSTALLING THE CORRECT FASTENERS. ON SEP/MON/01 THE AIRLINES QUALITY AND ASSURANCE DEPT CONTACTED ME TO QUESTION MY KNOWLEDGE AND RECOLLECTION OF THAT JOB. THEY INFORMED ME THAT I FAILED TO SEE THE ADDED DIRECTIVE NUMBER ON THE JOB CARD AND THAT THE DIRECTIVE SHOULD HAVE BEEN WITH THE WORK PACK. THE DIRECTIVE CALLED OUT AN ENGINEERING AUTHORITY THAT SPECIFIED THE FASTENERS THAT WERE TO BE INSTALLED. IF THIS PAPERWORK HAD BEEN WITH THE PACK THERE WOULD HAVE BEEN NO QUESTION AS TO HOW TO INSTALL THE PART. ALSO N SPEAKING WITH QUALITY AND ASSURANCE AND THE FAA REP I NOW KNOW THAT FOLLOWING VERBAL INSTRUCTION IS NOT A CORRECT SIGN OFF.
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.