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|
Attributes | |
ACN | 531347 |
Time | |
Date | 200111 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ilg.tower |
Operator | common carrier : air carrier |
Make Model Name | B777-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 3 maintenance technician : 16 |
ASRS Report | 531347 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
2 technicians on my shift took over a fan air modulation valve installation at start of shift. There was no time for operations check, so decision was made to defer and lock valve in the open position per MEL. Also, reverser was deactivated by pinning the pylon isolation valve. After deactivation, technicians forgot reverser pin removal and left reverser deactivated. Write-up was signed off by me and aircraft released after conferring with technicians that job was done and aircraft ready. After aircraft got to sfo, crew reported left reverser did not work on landing. Pin was discovered installed and access door hinges damaged. Aircraft took a 30 min delay in sfo and discrepancy was reported. Human performance: as a lead, I signed off on deferral and released plane to help mechanics get plane out sooner. I was taught by air carrier that this was legal as long as I conferred with mechanics performing work and also charging their work hours on signoff. 2 technicians that performed work assured me that the MEL was fully complied with and aircraft was ready for dispatch. I called dispatch and got approval for valve deferral and also released aircraft for flight. I am being implicated for this incident because of my signoff.
Original NASA ASRS Text
Title: A B777-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE L ENG FAN REVERSER LOCKED OUT. CAUSED BY FAILURE TO REMOVE LOCK PIN AFTER MAINT.
Narrative: 2 TECHNICIANS ON MY SHIFT TOOK OVER A FAN AIR MODULATION VALVE INSTALLATION AT START OF SHIFT. THERE WAS NO TIME FOR OPS CHK, SO DECISION WAS MADE TO DEFER AND LOCK VALVE IN THE OPEN POS PER MEL. ALSO, REVERSER WAS DEACTIVATED BY PINNING THE PYLON ISOLATION VALVE. AFTER DEACTIVATION, TECHNICIANS FORGOT REVERSER PIN REMOVAL AND LEFT REVERSER DEACTIVATED. WRITE-UP WAS SIGNED OFF BY ME AND ACFT RELEASED AFTER CONFERRING WITH TECHNICIANS THAT JOB WAS DONE AND ACFT READY. AFTER ACFT GOT TO SFO, CREW RPTED L REVERSER DID NOT WORK ON LNDG. PIN WAS DISCOVERED INSTALLED AND ACCESS DOOR HINGES DAMAGED. ACFT TOOK A 30 MIN DELAY IN SFO AND DISCREPANCY WAS RPTED. HUMAN PERFORMANCE: AS A LEAD, I SIGNED OFF ON DEFERRAL AND RELEASED PLANE TO HELP MECHS GET PLANE OUT SOONER. I WAS TAUGHT BY ACR THAT THIS WAS LEGAL AS LONG AS I CONFERRED WITH MECHS PERFORMING WORK AND ALSO CHARGING THEIR WORK HRS ON SIGNOFF. 2 TECHNICIANS THAT PERFORMED WORK ASSURED ME THAT THE MEL WAS FULLY COMPLIED WITH AND ACFT WAS READY FOR DISPATCH. I CALLED DISPATCH AND GOT APPROVAL FOR VALVE DEFERRAL AND ALSO RELEASED ACFT FOR FLT. I AM BEING IMPLICATED FOR THIS INCIDENT BECAUSE OF MY SIGNOFF.
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.