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|
Attributes | |
ACN | 557931 |
Time | |
Date | 200208 |
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 | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | L-1011-500 Series |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : fcc technician : powerplant |
Experience | maintenance avionics : 10 maintenance lead technician : 2 maintenance repairman : 3 maintenance technician : 6 |
ASRS Report | 557931 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : non availability of parts performance deficiency : logbook entry performance deficiency : installation performance deficiency : fault isolation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
This is the situation that lead me to installing the incorrect part on an aircraft, which lead to an aircraft being grounded, and a voluntary disclosure by my company X. I am a member of the right&east (radio and electronics) shop at company X. I was over helping line mechanics launch an aircraft, when another line mechanic, launching another aircraft, came to me and asked for assistance with the engine vibration indicators (all 3) not testing properly. I went over and began to troubleshoot. I narrowed it down to what I thought was the test switch on the front of the panel in which the indicators mount in. After checking the switch, it was determined to be good, so we took the entire panel over to another aircraft to see if it worked over there. I looked for part numbers on the panel, but couldn't find any. They looked the same (all the panel is, is 4 switches and some wiring), so I put it in. Keep in mind that at this time I was still troubleshooting. I installed it in the other aircraft, and it failed in the same manner as on the original aircraft. So then, just to verify, we took the known good panel over to the defective aircraft and tried it there, it tested good. I troubleshot on the defective panel for a while, but no luck. By this time the aircraft was over 1 hour delayed. So we (myself, maintenance supervisors, and maintenance control) decided that we would rob the panel from the aircraft that we were using to troubleshoot with. After installing the robbed panel on the aircraft, we did the operations check per the maintenance manual, and it checked good. While doing the logbook, I had to fill out a serviceable parts tag (known as an X-X0 at company X). While doing this, I found there was no special part number used by company X. So we called our aircraft on ground (priority parts order) parts people and had them create one. During this process, we looked in the ipc (illustrated parts catalog) for the defective aircraft to find a good manufacturer's part number for the panel. We found one, and that is the number we used. What we failed to do, is check the ipc of the aircraft we robbed the part from to see if the part numbers were the same, which would obviously prove if they were interchangeable or not. I finished the logbook, and the aircraft departed. At this time, my shift ended, and I went home. Apparently, when they went to order the new panel for the aircraft, which we robbed the panel from, it was determined that the panels were different for the 2 aircraft. I guess, maintenance control was contacted, and the aircraft was grounded upon landing. Just to reiterate, the system that was failed initially, did operationally check good per the maintenance manual after the incorrect panel was installed, and was not squawked by the flight crew upon landing, because it did function properly in-flight.
Original NASA ASRS Text
Title: A LOCKHEED L1011 WAS DISPATCHED IN NON COMPLIANCE WITH AN INCORRECT ENG VIBRATION TEST PANEL INSTALLED.
Narrative: THIS IS THE SIT THAT LEAD ME TO INSTALLING THE INCORRECT PART ON AN ACFT, WHICH LEAD TO AN ACFT BEING GNDED, AND A VOLUNTARY DISCLOSURE BY MY COMPANY X. I AM A MEMBER OF THE R&E (RADIO AND ELECTRONICS) SHOP AT COMPANY X. I WAS OVER HELPING LINE MECHS LAUNCH AN ACFT, WHEN ANOTHER LINE MECH, LAUNCHING ANOTHER ACFT, CAME TO ME AND ASKED FOR ASSISTANCE WITH THE ENG VIBRATION INDICATORS (ALL 3) NOT TESTING PROPERLY. I WENT OVER AND BEGAN TO TROUBLESHOOT. I NARROWED IT DOWN TO WHAT I THOUGHT WAS THE TEST SWITCH ON THE FRONT OF THE PANEL IN WHICH THE INDICATORS MOUNT IN. AFTER CHKING THE SWITCH, IT WAS DETERMINED TO BE GOOD, SO WE TOOK THE ENTIRE PANEL OVER TO ANOTHER ACFT TO SEE IF IT WORKED OVER THERE. I LOOKED FOR PART NUMBERS ON THE PANEL, BUT COULDN'T FIND ANY. THEY LOOKED THE SAME (ALL THE PANEL IS, IS 4 SWITCHES AND SOME WIRING), SO I PUT IT IN. KEEP IN MIND THAT AT THIS TIME I WAS STILL TROUBLESHOOTING. I INSTALLED IT IN THE OTHER ACFT, AND IT FAILED IN THE SAME MANNER AS ON THE ORIGINAL ACFT. SO THEN, JUST TO VERIFY, WE TOOK THE KNOWN GOOD PANEL OVER TO THE DEFECTIVE ACFT AND TRIED IT THERE, IT TESTED GOOD. I TROUBLESHOT ON THE DEFECTIVE PANEL FOR A WHILE, BUT NO LUCK. BY THIS TIME THE ACFT WAS OVER 1 HR DELAYED. SO WE (MYSELF, MAINT SUPVRS, AND MAINT CTL) DECIDED THAT WE WOULD ROB THE PANEL FROM THE ACFT THAT WE WERE USING TO TROUBLESHOOT WITH. AFTER INSTALLING THE ROBBED PANEL ON THE ACFT, WE DID THE OPS CHK PER THE MAINT MANUAL, AND IT CHKED GOOD. WHILE DOING THE LOGBOOK, I HAD TO FILL OUT A SERVICEABLE PARTS TAG (KNOWN AS AN X-X0 AT COMPANY X). WHILE DOING THIS, I FOUND THERE WAS NO SPECIAL PART NUMBER USED BY COMPANY X. SO WE CALLED OUR ACFT ON GND (PRIORITY PARTS ORDER) PARTS PEOPLE AND HAD THEM CREATE ONE. DURING THIS PROCESS, WE LOOKED IN THE IPC (ILLUSTRATED PARTS CATALOG) FOR THE DEFECTIVE ACFT TO FIND A GOOD MANUFACTURER'S PART NUMBER FOR THE PANEL. WE FOUND ONE, AND THAT IS THE NUMBER WE USED. WHAT WE FAILED TO DO, IS CHK THE IPC OF THE ACFT WE ROBBED THE PART FROM TO SEE IF THE PART NUMBERS WERE THE SAME, WHICH WOULD OBVIOUSLY PROVE IF THEY WERE INTERCHANGEABLE OR NOT. I FINISHED THE LOGBOOK, AND THE ACFT DEPARTED. AT THIS TIME, MY SHIFT ENDED, AND I WENT HOME. APPARENTLY, WHEN THEY WENT TO ORDER THE NEW PANEL FOR THE ACFT, WHICH WE ROBBED THE PANEL FROM, IT WAS DETERMINED THAT THE PANELS WERE DIFFERENT FOR THE 2 ACFT. I GUESS, MAINT CTL WAS CONTACTED, AND THE ACFT WAS GNDED UPON LNDG. JUST TO REITERATE, THE SYS THAT WAS FAILED INITIALLY, DID OPERATIONALLY CHK GOOD PER THE MAINT MANUAL AFTER THE INCORRECT PANEL WAS INSTALLED, AND WAS NOT SQUAWKED BY THE FLC UPON LNDG, BECAUSE IT DID FUNCTION PROPERLY INFLT.
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.