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|
Attributes | |
ACN | 538879 |
Time | |
Date | 200202 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : gmu.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-10 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : fcc technician : airframe technician : powerplant |
Experience | maintenance avionics : 2 maintenance lead technician : 6 maintenance technician : 14 |
ASRS Report | 538879 |
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 : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : unqualified personnel performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On the morning of feb/thu/02, I received a call from our maintenance controller to have aircraft X ready for an XB00 flight, due to a ship change. Aircraft was scheduled to be released on feb/fri/02 at XA00. I worked on deferring the maintenance left and had a technician go and install a row of passenger seats in the middle zone to take care of an MEL and we could then unblock those seats. The technician had about 1 hour to get the job done and he was new in our area. I didn't have a chance to supervise the installation due to the paperwork I was taking care of in the office. At XA15 I went out to the aircraft to collect the paperwork and see how the job was coming along. The technician was completing the operations checks on the seat. I grabbed the XXXX identify tag on the seats and looked to see if the oxygen canisters were already installed. The tag stated the seats had the canisters installed and the rii inspection was not necessary. I had the technician sign off the log page and then I proceeded to the office to where I north/a'ed the inspection block for the job and released the aircraft for flight. The technician never checked under the seat cushions to see if the oxygen canisters were ever installed. The flight left for orlando, fl, and our day shift crew was taking the row of seats back to stock when they noticed the old canisters were still on the seats. The main cause for the incident was the fact our seats were tagged stating the oxygen canisters were installed, when in fact they weren't. After the incident I went back into our stores to look at the other seats coming from our vendors. None of the seats had tags saying the canisters weren't installed -- they were all the same as the tag we saw on feb/thu/02.
Original NASA ASRS Text
Title: A DC10-40 WAS DISPATCHED IN NON COMPLIANCE WITH A PAX SEAT INSTALLED WITHOUT AN OXYGEN CANISTER. CAUSED BY INCORRECT PARTS TAG AND NO INSPECTION.
Narrative: ON THE MORNING OF FEB/THU/02, I RECEIVED A CALL FROM OUR MAINT CTLR TO HAVE ACFT X READY FOR AN XB00 FLT, DUE TO A SHIP CHANGE. ACFT WAS SCHEDULED TO BE RELEASED ON FEB/FRI/02 AT XA00. I WORKED ON DEFERRING THE MAINT LEFT AND HAD A TECHNICIAN GO AND INSTALL A ROW OF PAX SEATS IN THE MIDDLE ZONE TO TAKE CARE OF AN MEL AND WE COULD THEN UNBLOCK THOSE SEATS. THE TECHNICIAN HAD ABOUT 1 HR TO GET THE JOB DONE AND HE WAS NEW IN OUR AREA. I DIDN'T HAVE A CHANCE TO SUPERVISE THE INSTALLATION DUE TO THE PAPERWORK I WAS TAKING CARE OF IN THE OFFICE. AT XA15 I WENT OUT TO THE ACFT TO COLLECT THE PAPERWORK AND SEE HOW THE JOB WAS COMING ALONG. THE TECHNICIAN WAS COMPLETING THE OPS CHKS ON THE SEAT. I GRABBED THE XXXX IDENT TAG ON THE SEATS AND LOOKED TO SEE IF THE OXYGEN CANISTERS WERE ALREADY INSTALLED. THE TAG STATED THE SEATS HAD THE CANISTERS INSTALLED AND THE RII INSPECTION WAS NOT NECESSARY. I HAD THE TECHNICIAN SIGN OFF THE LOG PAGE AND THEN I PROCEEDED TO THE OFFICE TO WHERE I N/A'ED THE INSPECTION BLOCK FOR THE JOB AND RELEASED THE ACFT FOR FLT. THE TECHNICIAN NEVER CHKED UNDER THE SEAT CUSHIONS TO SEE IF THE OXYGEN CANISTERS WERE EVER INSTALLED. THE FLT LEFT FOR ORLANDO, FL, AND OUR DAY SHIFT CREW WAS TAKING THE ROW OF SEATS BACK TO STOCK WHEN THEY NOTICED THE OLD CANISTERS WERE STILL ON THE SEATS. THE MAIN CAUSE FOR THE INCIDENT WAS THE FACT OUR SEATS WERE TAGGED STATING THE OXYGEN CANISTERS WERE INSTALLED, WHEN IN FACT THEY WEREN'T. AFTER THE INCIDENT I WENT BACK INTO OUR STORES TO LOOK AT THE OTHER SEATS COMING FROM OUR VENDORS. NONE OF THE SEATS HAD TAGS SAYING THE CANISTERS WEREN'T INSTALLED -- THEY WERE ALL THE SAME AS THE TAG WE SAW ON FEB/THU/02.
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.