37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 537332 |
Time | |
Date | 200202 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Experience | maintenance technician : 13 |
ASRS Report | 537332 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Situations | |
Publication | CHANGE ORDER JOB CARDS |
Narrative:
I am writing this letter to the program involving myself and possibly other mechanics and other air carrier X fleet jets. This concerns the phone deactivation, and specifically the circuit breaker removal and capping of wires. The paperwork specifically asks the mechanic to go to 1 circuit breaker panel, which is the P-18-2 panel located behind the captain's seat next to the floor where the phone breaker is located. It asks you to remove the phone breaker and cap those wires, the power feeder cable (3 phase) and cap and stow the load side wires. 6 wires in all. The paperwork does not direct you to go to the P-18-4 panel where the terminal block is located. I realized on my second breaker deactivation that this was being asked for which was early feb/sun/02 morning (XA00). I went to my foreman with the paperwork and we both read it several times and felt it best to contact engineering. Over the past 13 yrs at air carrier I have done many modifications on side wall light ballasts which are hard-wired and have done a few main gear sensors. My point is this: that I felt if I could miss this, so could someone else -- especially those with little electrical experience. On the night of feb/sun/02 I worked overtime on the line (XA30 to XL00). Aircraft XXX was on gate X. Out of sheer curiosity, I wanted to see if this wire situation had been missed on this aircraft that had the phones and breakers pulled by another mechanic. The wires were still connected, not capped and stowed. I again talked to abc line foreman. He contacted engineering. Mr X told me that engineering would most likely issue a service instruction to inspect all aircraft that had phones deactivated. As I began writing this letter late thursday night at the hangar in ZZZ, I understand that a service instruction has been issued to reinspect. I also understand that a revision 2 for the phone and breaker deactivation has also been issued on jan/thu/02. Callback conversation with reporter revealed the following information: the reporter stated the original engineering change order did not state to remove and cap the wiring on the terminal block behind the P-18-4 circuit breaker panel. The reporter said the parts kit contained 9 wire termination caps, 6 were used on the 3 phase power circuit breaker wires and no mention was made of capping the terminal block wires behind the P-18-4 panel. The reporter stated there were 4 revisions made to this change order before it was clear and concise.
Original NASA ASRS Text
Title: A B737-300 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH AIRPHONE SYS DEACTIVATION CHANGE ORDER WIRING INCOMPLETE. CAUSED BY VAGUE AND CONFUSING WORK CARDS.
Narrative: I AM WRITING THIS LETTER TO THE PROGRAM INVOLVING MYSELF AND POSSIBLY OTHER MECHS AND OTHER ACR X FLEET JETS. THIS CONCERNS THE PHONE DEACTIVATION, AND SPECIFICALLY THE CIRCUIT BREAKER REMOVAL AND CAPPING OF WIRES. THE PAPERWORK SPECIFICALLY ASKS THE MECH TO GO TO 1 CIRCUIT BREAKER PANEL, WHICH IS THE P-18-2 PANEL LOCATED BEHIND THE CAPT'S SEAT NEXT TO THE FLOOR WHERE THE PHONE BREAKER IS LOCATED. IT ASKS YOU TO REMOVE THE PHONE BREAKER AND CAP THOSE WIRES, THE PWR FEEDER CABLE (3 PHASE) AND CAP AND STOW THE LOAD SIDE WIRES. 6 WIRES IN ALL. THE PAPERWORK DOES NOT DIRECT YOU TO GO TO THE P-18-4 PANEL WHERE THE TERMINAL BLOCK IS LOCATED. I REALIZED ON MY SECOND BREAKER DEACTIVATION THAT THIS WAS BEING ASKED FOR WHICH WAS EARLY FEB/SUN/02 MORNING (XA00). I WENT TO MY FOREMAN WITH THE PAPERWORK AND WE BOTH READ IT SEVERAL TIMES AND FELT IT BEST TO CONTACT ENGINEERING. OVER THE PAST 13 YRS AT ACR I HAVE DONE MANY MODIFICATIONS ON SIDE WALL LIGHT BALLASTS WHICH ARE HARD-WIRED AND HAVE DONE A FEW MAIN GEAR SENSORS. MY POINT IS THIS: THAT I FELT IF I COULD MISS THIS, SO COULD SOMEONE ELSE -- ESPECIALLY THOSE WITH LITTLE ELECTRICAL EXPERIENCE. ON THE NIGHT OF FEB/SUN/02 I WORKED OVERTIME ON THE LINE (XA30 TO XL00). ACFT XXX WAS ON GATE X. OUT OF SHEER CURIOSITY, I WANTED TO SEE IF THIS WIRE SIT HAD BEEN MISSED ON THIS ACFT THAT HAD THE PHONES AND BREAKERS PULLED BY ANOTHER MECH. THE WIRES WERE STILL CONNECTED, NOT CAPPED AND STOWED. I AGAIN TALKED TO ABC LINE FOREMAN. HE CONTACTED ENGINEERING. MR X TOLD ME THAT ENGINEERING WOULD MOST LIKELY ISSUE A SVC INSTRUCTION TO INSPECT ALL ACFT THAT HAD PHONES DEACTIVATED. AS I BEGAN WRITING THIS LETTER LATE THURSDAY NIGHT AT THE HANGAR IN ZZZ, I UNDERSTAND THAT A SVC INSTRUCTION HAS BEEN ISSUED TO REINSPECT. I ALSO UNDERSTAND THAT A REVISION 2 FOR THE PHONE AND BREAKER DEACTIVATION HAS ALSO BEEN ISSUED ON JAN/THU/02. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ORIGINAL ENGINEERING CHANGE ORDER DID NOT STATE TO REMOVE AND CAP THE WIRING ON THE TERMINAL BLOCK BEHIND THE P-18-4 CIRCUIT BREAKER PANEL. THE RPTR SAID THE PARTS KIT CONTAINED 9 WIRE TERMINATION CAPS, 6 WERE USED ON THE 3 PHASE PWR CIRCUIT BREAKER WIRES AND NO MENTION WAS MADE OF CAPPING THE TERMINAL BLOCK WIRES BEHIND THE P-18-4 PANEL. THE RPTR STATED THERE WERE 4 REVISIONS MADE TO THIS CHANGE ORDER BEFORE IT WAS CLR AND CONCISE.
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.