37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 560168 |
Time | |
Date | 200209 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
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 | B737-500 |
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 | 560168 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation non adherence : published procedure non adherence : far non adherence : company policies |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : non availability of parts performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X had an inoperative #1 navigation control panel. Duty center sent me to rob aircraft Y for #1 navigation control panel. Having just recently reopened a stock of robbed parts tags, I stopped by the office, grabbed one and proceeded to complete all the paperwork to complete the job, except a serviceable parts tag. I found out later at shift change, one is required. Sep/wed/02, I got to work, called duty center to verify the need of a serviceable tag. First controller said, 'no,' we do it all the time. I checked with the lead controller next. He said 'yes.' I informed him of the mistake. He referred me to qc supervisor, who referred me to a receiving inspector. I explained the situation again and asked him to print a tag so I could telecom the removable installation information for the unit and he insisted we just make it serviceable in the computer. At this point I thought that a serviceable tag should be printed and filled out, not just a tag number issued in the computer. I can only attribute this mistake to my actions because ultimately, I am responsible. I simply had the rob parts tag in mind and neglected to remember the serviceable tag. Future incidences could be avoided by duty center if they had a quick reference guide for paperwork, that had a table for all required and associated paperwork for this and other kinds of maintenance action. Appropriate maintenance manual procedures were followed in installation and for heads up display upgrade.
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED IN NON COMPLIANCE WITH REMOVED NAV CTL PANEL PARTS TAG NOT COMPLETED AND PART NOT TAGGED.
Narrative: ACFT X HAD AN INOP #1 NAV CTL PANEL. DUTY CTR SENT ME TO ROB ACFT Y FOR #1 NAV CTL PANEL. HAVING JUST RECENTLY REOPENED A STOCK OF ROBBED PARTS TAGS, I STOPPED BY THE OFFICE, GRABBED ONE AND PROCEEDED TO COMPLETE ALL THE PAPERWORK TO COMPLETE THE JOB, EXCEPT A SERVICEABLE PARTS TAG. I FOUND OUT LATER AT SHIFT CHANGE, ONE IS REQUIRED. SEP/WED/02, I GOT TO WORK, CALLED DUTY CTR TO VERIFY THE NEED OF A SERVICEABLE TAG. FIRST CTLR SAID, 'NO,' WE DO IT ALL THE TIME. I CHKED WITH THE LEAD CTLR NEXT. HE SAID 'YES.' I INFORMED HIM OF THE MISTAKE. HE REFERRED ME TO QC SUPVR, WHO REFERRED ME TO A RECEIVING INSPECTOR. I EXPLAINED THE SIT AGAIN AND ASKED HIM TO PRINT A TAG SO I COULD TELECOM THE REMOVABLE INSTALLATION INFO FOR THE UNIT AND HE INSISTED WE JUST MAKE IT SERVICEABLE IN THE COMPUTER. AT THIS POINT I THOUGHT THAT A SERVICEABLE TAG SHOULD BE PRINTED AND FILLED OUT, NOT JUST A TAG NUMBER ISSUED IN THE COMPUTER. I CAN ONLY ATTRIBUTE THIS MISTAKE TO MY ACTIONS BECAUSE ULTIMATELY, I AM RESPONSIBLE. I SIMPLY HAD THE ROB PARTS TAG IN MIND AND NEGLECTED TO REMEMBER THE SERVICEABLE TAG. FUTURE INCIDENCES COULD BE AVOIDED BY DUTY CTR IF THEY HAD A QUICK REF GUIDE FOR PAPERWORK, THAT HAD A TABLE FOR ALL REQUIRED AND ASSOCIATED PAPERWORK FOR THIS AND OTHER KINDS OF MAINT ACTION. APPROPRIATE MAINT MANUAL PROCS WERE FOLLOWED IN INSTALLATION AND FOR HEADS UP DISPLAY UPGRADE.
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.