37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 544347 |
Time | |
Date | 200204 |
Day | Tue |
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 |
Qualification | technician : fcc technician : powerplant technician : airframe |
Experience | maintenance lead technician : 1 maintenance technician : 19 |
ASRS Report | 544347 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far other anomaly other |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Company Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Narrative:
The work release for aircraft XXX required that the cockpit voice recorder be changed due to the beacon battery expiring at the end of the month. The work release specified company part #XXXX cockpit voice recorder be installed, and this part number cockpit voice recorder was shipped in and placed on the remain overnight [routine overnight layover] parts shelf designated for aircraft XXX during installation. I noticed that there were physical differences from the unit I removed, but that is often the case with numerous components. Because of this, I did check the 3 keyed locating pins on the back of the units and found them to be the same. Later that shift, I was standing in the forward galley signing the logbook and requested my partner (another a&P), who was in the cockpit, to test the cockpit voice recorder. He did, and said that the test was normal. I made the entry in the logbook indicating the work performed and the test result. On apr/tue/02, I was notified by the maintenance foreman that an error had been made, and the company had self-disclosed it to the FAA. The cockpit voice recorder I had installed was the incorrect party number due to the part number of the cockpit voice recorder control panel installed in the cockpit. The control panel part number is XXXX. The panel used with this cockpit voice recorder is part number YYYY. The correct part number cockpit voice recorder for this panel is ZZZZ. Normally the company computer system would generate an error message whenever a part that is incorrect is installed (upon logbook data entry). This did not occur. In other instances of similar parts that require specific matches to other components, the company inserts a special notification tag in with the parts tag. This did not occur either. I believe this error occurred due to the combination of: 1) the work release specifying which pat to use. 2) the fact that the unit was able to be fitted into the rack normally, ie, the keyed located pins. 3) that a valid test was obtained. 4) that the company computer system did not indicate that an incorrect part was used. To prevent this from happening again, I would suggest that the company insert a special notice tag in with the tag indicating that the mechanic should check compatibility with the control panel installed. This system is already in use with other parts combinations such as certain main wheel and axle spacer combinations.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT COCKPIT VOICE RECORDER INSTALLED, DUE TO WORK JOB CARD ERROR.
Narrative: THE WORK RELEASE FOR ACFT XXX REQUIRED THAT THE COCKPIT VOICE RECORDER BE CHANGED DUE TO THE BEACON BATTERY EXPIRING AT THE END OF THE MONTH. THE WORK RELEASE SPECIFIED COMPANY PART #XXXX COCKPIT VOICE RECORDER BE INSTALLED, AND THIS PART NUMBER COCKPIT VOICE RECORDER WAS SHIPPED IN AND PLACED ON THE REMAIN OVERNIGHT [ROUTINE OVERNIGHT LAYOVER] PARTS SHELF DESIGNATED FOR ACFT XXX DURING INSTALLATION. I NOTICED THAT THERE WERE PHYSICAL DIFFERENCES FROM THE UNIT I REMOVED, BUT THAT IS OFTEN THE CASE WITH NUMEROUS COMPONENTS. BECAUSE OF THIS, I DID CHK THE 3 KEYED LOCATING PINS ON THE BACK OF THE UNITS AND FOUND THEM TO BE THE SAME. LATER THAT SHIFT, I WAS STANDING IN THE FORWARD GALLEY SIGNING THE LOGBOOK AND REQUESTED MY PARTNER (ANOTHER A&P), WHO WAS IN THE COCKPIT, TO TEST THE COCKPIT VOICE RECORDER. HE DID, AND SAID THAT THE TEST WAS NORMAL. I MADE THE ENTRY IN THE LOGBOOK INDICATING THE WORK PERFORMED AND THE TEST RESULT. ON APR/TUE/02, I WAS NOTIFIED BY THE MAINT FOREMAN THAT AN ERROR HAD BEEN MADE, AND THE COMPANY HAD SELF-DISCLOSED IT TO THE FAA. THE COCKPIT VOICE RECORDER I HAD INSTALLED WAS THE INCORRECT PARTY NUMBER DUE TO THE PART NUMBER OF THE COCKPIT VOICE RECORDER CTL PANEL INSTALLED IN THE COCKPIT. THE CTL PANEL PART NUMBER IS XXXX. THE PANEL USED WITH THIS COCKPIT VOICE RECORDER IS PART NUMBER YYYY. THE CORRECT PART NUMBER COCKPIT VOICE RECORDER FOR THIS PANEL IS ZZZZ. NORMALLY THE COMPANY COMPUTER SYS WOULD GENERATE AN ERROR MESSAGE WHENEVER A PART THAT IS INCORRECT IS INSTALLED (UPON LOGBOOK DATA ENTRY). THIS DID NOT OCCUR. IN OTHER INSTANCES OF SIMILAR PARTS THAT REQUIRE SPECIFIC MATCHES TO OTHER COMPONENTS, THE COMPANY INSERTS A SPECIAL NOTIFICATION TAG IN WITH THE PARTS TAG. THIS DID NOT OCCUR EITHER. I BELIEVE THIS ERROR OCCURRED DUE TO THE COMBINATION OF: 1) THE WORK RELEASE SPECIFYING WHICH PAT TO USE. 2) THE FACT THAT THE UNIT WAS ABLE TO BE FITTED INTO THE RACK NORMALLY, IE, THE KEYED LOCATED PINS. 3) THAT A VALID TEST WAS OBTAINED. 4) THAT THE COMPANY COMPUTER SYS DID NOT INDICATE THAT AN INCORRECT PART WAS USED. TO PREVENT THIS FROM HAPPENING AGAIN, I WOULD SUGGEST THAT THE COMPANY INSERT A SPECIAL NOTICE TAG IN WITH THE TAG INDICATING THAT THE MECH SHOULD CHK COMPATIBILITY WITH THE CTL PANEL INSTALLED. THIS SYS IS ALREADY IN USE WITH OTHER PARTS COMBINATIONS SUCH AS CERTAIN MAIN WHEEL AND AXLE SPACER COMBINATIONS.
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.