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B767-200 mechanic did not reconnect the cannon plugs leading edge slat drive electrical plugs after routine maintenance.
| Attributes | |
| ACN | 557870 |
| Time | |
| Date | 200208 |
| Day | Fri |
| Local Time Of Day | 1801 To 2400 |
| 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 | B767-200 |
| 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 : 31 |
| ASRS Report | 557870 |
| Person 2 | |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far other anomaly other |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact other |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : briefing contributing factor : manuals contributing factor : work cards performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Company |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X was undergoing maintenance in hangar at ZZZ. Engine cowlings were open and therefore the leading edge slats are to be deactivated. There was a write-up in the non routines of the work pack stating the inboard slats were deactivated in accordance with B767A maintenance manual 27-81-00-2 paragraph 9E. After all work was accomplished I reactivated the slats. Not noticing the paragraph 9E in the write-up I proceeded to reactivate the slats the way we always do, by the standard procedure of B767A maintenance manual 27-81-00-2 paragraph 2 for primary method, or paragraph 3, the alternate method. Consequently in accordance with paragraph 9E, 2 cannon plugs were left disconnected which electrically operate the slats, so when out-base mechanics tried operating the slats electrically the inboard slats were inoperative. The cannon plugs were reconnected and the system worked fine. I believe this would not have occurred if reason for using a different procedure had been in the write-up.
Original NASA ASRS Text
Title: B767-200 MECH DID NOT RECONNECT THE CANNON PLUGS LEADING EDGE SLAT DRIVE ELECTRICAL PLUGS AFTER ROUTINE MAINT.
Narrative: ACFT X WAS UNDERGOING MAINT IN HANGAR AT ZZZ. ENG COWLINGS WERE OPEN AND THEREFORE THE LEADING EDGE SLATS ARE TO BE DEACTIVATED. THERE WAS A WRITE-UP IN THE NON ROUTINES OF THE WORK PACK STATING THE INBOARD SLATS WERE DEACTIVATED IN ACCORDANCE WITH B767A MAINT MANUAL 27-81-00-2 PARAGRAPH 9E. AFTER ALL WORK WAS ACCOMPLISHED I REACTIVATED THE SLATS. NOT NOTICING THE PARAGRAPH 9E IN THE WRITE-UP I PROCEEDED TO REACTIVATE THE SLATS THE WAY WE ALWAYS DO, BY THE STANDARD PROC OF B767A MAINT MANUAL 27-81-00-2 PARAGRAPH 2 FOR PRIMARY METHOD, OR PARAGRAPH 3, THE ALTERNATE METHOD. CONSEQUENTLY IN ACCORDANCE WITH PARAGRAPH 9E, 2 CANNON PLUGS WERE LEFT DISCONNECTED WHICH ELECTRICALLY OPERATE THE SLATS, SO WHEN OUT-BASE MECHS TRIED OPERATING THE SLATS ELECTRICALLY THE INBOARD SLATS WERE INOP. THE CANNON PLUGS WERE RECONNECTED AND THE SYS WORKED FINE. I BELIEVE THIS WOULD NOT HAVE OCCURRED IF REASON FOR USING A DIFFERENT PROC HAD BEEN IN THE WRITE-UP.
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.