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A B737-200 during an auxiliary power unit change was found by a FAA safety inspector to be in violation of safety and manual procedures.
| Attributes | |
| ACN | 532826 |
| Time | |
| Date | 200112 |
| Day | Mon |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 msl single value : 0 |
| Environment | |
| Light | Dawn |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-200 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : powerplant technician : repairman |
| Experience | maintenance lead technician : 5 |
| ASRS Report | 532826 |
| Person 2 | |
| Affiliation | government : faa |
| Function | other personnel other |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | faa : assigned or threatened penalties other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : installation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | FAA Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Was line overnight check lead on duty. Aircraft went to hangar for APU change. When FAA arrived at hangar paperwork was not complete to the point of not being signed off to the step that the mechanics were on. But all maintenance manual references and check forms were in the immediate area mechanics were working in. Also circuit breakers were not pulled on aircraft, but the power was off and disconnected and the aircraft was grounded. Also please note that the mechanics assigned to the job are qualified to do the job and are both very competent mechanics. Aircraft did not get to the hangar till XA00 and was scheduled for a XC15 departure. Mechanics were under heavy time constraints and felt that by not having power connected to aircraft was sufficient for circuit breaker not being pulled. Also, please note that we have from 12 to 18 airplanes on line check and only two lead and that the leads can not concentrate on just one assigned airplane.
Original NASA ASRS Text
Title: A B737-200 DURING AN AUXILIARY PWR UNIT CHANGE WAS FOUND BY A FAA SAFETY INSPECTOR TO BE IN VIOLATION OF SAFETY AND MANUAL PROCS.
Narrative: WAS LINE OVERNIGHT CHECK LEAD ON DUTY. ACFT WENT TO HANGAR FOR APU CHANGE. WHEN FAA ARRIVED AT HANGAR PAPERWORK WAS NOT COMPLETE TO THE POINT OF NOT BEING SIGNED OFF TO THE STEP THAT THE MECHANICS WERE ON. BUT ALL MAINT MANUAL REFERENCES AND CHECK FORMS WERE IN THE IMMEDIATE AREA MECHANICS WERE WORKING IN. ALSO CIRCUIT BREAKERS WERE NOT PULLED ON ACFT, BUT THE PWR WAS OFF AND DISCONNECTED AND THE ACFT WAS GNDED. ALSO PLEASE NOTE THAT THE MECHANICS ASSIGNED TO THE JOB ARE QUALIFIED TO DO THE JOB AND ARE BOTH VERY COMPETENT MECHANICS. ACFT DID NOT GET TO THE HANGAR TILL XA00 AND WAS SCHEDULED FOR A XC15 DEP. MECHANICS WERE UNDER HVY TIME CONSTRAINTS AND FELT THAT BY NOT HAVING PWR CONNECTED TO ACFT WAS SUFFICIENT FOR CIRCUIT BREAKER NOT BEING PULLED. ALSO, PLEASE NOTE THAT WE HAVE FROM 12 TO 18 AIRPLANES ON LINE CHECK AND ONLY TWO LEAD AND THAT THE LEADS CAN NOT CONCENTRATE ON JUST ONE ASSIGNED AIRPLANE.
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.