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|
Attributes | |
ACN | 547926 |
Time | |
Date | 200205 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : lax.tower |
Operator | common carrier : air carrier |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 4 |
ASRS Report | 547926 |
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 : company policies non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
During an ETOPS service check, I was pressured into performing maintenance that I was not qualified to perform. A qualified mechanic told me to do the work and he would sign for it. Overwater job card was complied with and the aircraft departed ZZZ1 and diverted into ZZZ2 after an in-flight shutdown due to loss of oil pressure on #2 engine. After being informed the next day of the situation, I found documentation in training records stating that I was not qualified to perform the maintenance regardless of who signed for the work. I was informed that the in-flight shutdown was caused due to an oil sump line not safety wired. I recall doublechking the torque on the line and not seeing a place to safety the line. The line was leak checked twice after maintenance was complete. Some of the human factors involved are due to working late at night in the dark and pouring rain. Other factors involve other qualified amt's not doing their job, forcing me to pick up the slack out of fear of being reprimanded by lead amt's and supervisors. There were many other ETOPS qualified amt's at work that night that were not assigned to that aircraft thus forcing non-equipment-qualified amt's to do work they are not qualified for.
Original NASA ASRS Text
Title: A B767-400 TECHNICIAN RPTS BEING PRESSURED INTO PERFORMING MAINT THAT HE WAS UNTRAINED AND UNQUALIFIED TO PERFORM, RESULTING IN AN ENG SHUTDOWN.
Narrative: DURING AN ETOPS SVC CHK, I WAS PRESSURED INTO PERFORMING MAINT THAT I WAS NOT QUALIFIED TO PERFORM. A QUALIFIED MECH TOLD ME TO DO THE WORK AND HE WOULD SIGN FOR IT. OVERWATER JOB CARD WAS COMPLIED WITH AND THE ACFT DEPARTED ZZZ1 AND DIVERTED INTO ZZZ2 AFTER AN INFLT SHUTDOWN DUE TO LOSS OF OIL PRESSURE ON #2 ENG. AFTER BEING INFORMED THE NEXT DAY OF THE SIT, I FOUND DOCUMENTATION IN TRAINING RECORDS STATING THAT I WAS NOT QUALIFIED TO PERFORM THE MAINT REGARDLESS OF WHO SIGNED FOR THE WORK. I WAS INFORMED THAT THE INFLT SHUTDOWN WAS CAUSED DUE TO AN OIL SUMP LINE NOT SAFETY WIRED. I RECALL DOUBLECHKING THE TORQUE ON THE LINE AND NOT SEEING A PLACE TO SAFETY THE LINE. THE LINE WAS LEAK CHKED TWICE AFTER MAINT WAS COMPLETE. SOME OF THE HUMAN FACTORS INVOLVED ARE DUE TO WORKING LATE AT NIGHT IN THE DARK AND POURING RAIN. OTHER FACTORS INVOLVE OTHER QUALIFIED AMT'S NOT DOING THEIR JOB, FORCING ME TO PICK UP THE SLACK OUT OF FEAR OF BEING REPRIMANDED BY LEAD AMT'S AND SUPVRS. THERE WERE MANY OTHER ETOPS QUALIFIED AMT'S AT WORK THAT NIGHT THAT WERE NOT ASSIGNED TO THAT ACFT THUS FORCING NON-EQUIP-QUALIFIED AMT'S TO DO WORK THEY ARE NOT QUALIFIED FOR.
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.