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|
Attributes | |
ACN | 553065 |
Time | |
Date | 200206 |
Day | Sat |
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 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 553065 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : 969 |
Consequence | other |
Factors | |
Maintenance | performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The problem arose from a repetitive #1 CSD oil temperature high discrepancy whereas the #1 CSD was removed and replaced just a few days prior to any maintenance that I performed. The replacement CSD did not fix the problem. The aircraft then came to ZZZ on the night in question with the same discrepancy. After an engine run it was collectively decided that we would change the #1 CSD oil collar, #1 CSD oil temperature indictor, and the stand-by power module. All the items were changed simultaneously due to noise restr requirements at night for the high power engine run and time constraints for morning departure. After changing the CSD oil cooler, another mechanic and I went to the maintenance office to get the replacement CSD oil temperature indicator and stand-by power module. At the maintenance desk where the ron aircraft logbooks and work packages are kept was a stand-by power module waiting for us. We took the module (assuming that whomever pulled the part off the stockroom shelf and put it in there for us to use on our aircraft had already verified effectivity) and a CSD oil temperature indicator back to the aircraft where we removed and replaced both parts. All indications were normal during the subsequent engine run and leak check after the maintenance was performed. Apparently, the quality assurance department found the improper part number stand-by power module and it was removed and replaced with the correct effectivity stand-by power module. In order to prevent recurrence I feel that I will have to 'doublechk' part numbers and aircraft effectivity when given a part to install on an aircraft. I realize that I, as the mechanic, am ultimately responsible for the correct installation of the correct parts on the aircraft but future incidents may be prevented by some additional form of differentiation on parts that look similar but are not. Increased mechanic awareness (such as I have obtained from this incident) will also aid in the proper maintenance practices of our aircraft.
Original NASA ASRS Text
Title: A B737 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT STANDBY PWR MODULE INSTALLED.
Narrative: THE PROB AROSE FROM A REPETITIVE #1 CSD OIL TEMP HIGH DISCREPANCY WHEREAS THE #1 CSD WAS REMOVED AND REPLACED JUST A FEW DAYS PRIOR TO ANY MAINT THAT I PERFORMED. THE REPLACEMENT CSD DID NOT FIX THE PROB. THE ACFT THEN CAME TO ZZZ ON THE NIGHT IN QUESTION WITH THE SAME DISCREPANCY. AFTER AN ENG RUN IT WAS COLLECTIVELY DECIDED THAT WE WOULD CHANGE THE #1 CSD OIL COLLAR, #1 CSD OIL TEMP INDICTOR, AND THE STAND-BY PWR MODULE. ALL THE ITEMS WERE CHANGED SIMULTANEOUSLY DUE TO NOISE RESTR REQUIREMENTS AT NIGHT FOR THE HIGH PWR ENG RUN AND TIME CONSTRAINTS FOR MORNING DEP. AFTER CHANGING THE CSD OIL COOLER, ANOTHER MECH AND I WENT TO THE MAINT OFFICE TO GET THE REPLACEMENT CSD OIL TEMP INDICATOR AND STAND-BY PWR MODULE. AT THE MAINT DESK WHERE THE RON ACFT LOGBOOKS AND WORK PACKAGES ARE KEPT WAS A STAND-BY PWR MODULE WAITING FOR US. WE TOOK THE MODULE (ASSUMING THAT WHOMEVER PULLED THE PART OFF THE STOCKROOM SHELF AND PUT IT IN THERE FOR US TO USE ON OUR ACFT HAD ALREADY VERIFIED EFFECTIVITY) AND A CSD OIL TEMP INDICATOR BACK TO THE ACFT WHERE WE REMOVED AND REPLACED BOTH PARTS. ALL INDICATIONS WERE NORMAL DURING THE SUBSEQUENT ENG RUN AND LEAK CHK AFTER THE MAINT WAS PERFORMED. APPARENTLY, THE QUALITY ASSURANCE DEPT FOUND THE IMPROPER PART NUMBER STAND-BY PWR MODULE AND IT WAS REMOVED AND REPLACED WITH THE CORRECT EFFECTIVITY STAND-BY PWR MODULE. IN ORDER TO PREVENT RECURRENCE I FEEL THAT I WILL HAVE TO 'DOUBLECHK' PART NUMBERS AND ACFT EFFECTIVITY WHEN GIVEN A PART TO INSTALL ON AN ACFT. I REALIZE THAT I, AS THE MECH, AM ULTIMATELY RESPONSIBLE FOR THE CORRECT INSTALLATION OF THE CORRECT PARTS ON THE ACFT BUT FUTURE INCIDENTS MAY BE PREVENTED BY SOME ADDITIONAL FORM OF DIFFERENTIATION ON PARTS THAT LOOK SIMILAR BUT ARE NOT. INCREASED MECH AWARENESS (SUCH AS I HAVE OBTAINED FROM THIS INCIDENT) WILL ALSO AID IN THE PROPER MAINT PRACTICES OF OUR ACFT.
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.