37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 559963 |
Time | |
Date | 200112 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 18 |
ASRS Report | 559963 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : engineering procedure performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : repair |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On dec/mon/01, I on logged a 3RD stage disk part number X, serial number Y, to a PW4000 engine turbine module number Z. Through my training I was shown to follow on the condition sheet what the previous inspectors had marked had on logged. In this case all the newly on logged parts were a 'G' confign on 'all' type. So I followed suit and on logged a 'G' confign T-3 disk for installation. I was informed with documentation on sep/tue/02, by my supervisor that I had on logged the T-3 disk but that the T-3 disk which hadn't been removed was a confign 'F.' that also up until this time had been told by my supervisor that the checking of confign was only a courtesy by the on log inspector and also by mechanic who installs the parts, but that it was planning's responsibility for the configns.
Original NASA ASRS Text
Title: A TURBINE SHOP INSPECTOR RPTS LOGGING A REPLACEMENT TURBINE DISC INCORRECTLY AS A PART THAT COULD BE USED IN ANY CONFIGN.
Narrative: ON DEC/MON/01, I ON LOGGED A 3RD STAGE DISK PART NUMBER X, SERIAL NUMBER Y, TO A PW4000 ENG TURBINE MODULE NUMBER Z. THROUGH MY TRAINING I WAS SHOWN TO FOLLOW ON THE CONDITION SHEET WHAT THE PREVIOUS INSPECTORS HAD MARKED HAD ON LOGGED. IN THIS CASE ALL THE NEWLY ON LOGGED PARTS WERE A 'G' CONFIGN ON 'ALL' TYPE. SO I FOLLOWED SUIT AND ON LOGGED A 'G' CONFIGN T-3 DISK FOR INSTALLATION. I WAS INFORMED WITH DOCUMENTATION ON SEP/TUE/02, BY MY SUPVR THAT I HAD ON LOGGED THE T-3 DISK BUT THAT THE T-3 DISK WHICH HADN'T BEEN REMOVED WAS A CONFIGN 'F.' THAT ALSO UP UNTIL THIS TIME HAD BEEN TOLD BY MY SUPVR THAT THE CHKING OF CONFIGN WAS ONLY A COURTESY BY THE ON LOG INSPECTOR AND ALSO BY MECH WHO INSTALLS THE PARTS, BUT THAT IT WAS PLANNING'S RESPONSIBILITY FOR THE CONFIGNS.
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.