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|
Attributes | |
ACN | 564087 |
Time | |
Date | 200210 |
Day | Mon |
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 | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 564087 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 564088 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Worked overtime on hangar and performed service check on aircraft, tab insp was performed on aircraft by other hangar personnel, aircraft required maintenance note to carryover functional flight check due to elevator tab hinge bolt replacement, logbook was done properly, but MEL stickers were not placed in cockpit properly by mechanic doing maintenance note on aircraft. Airworthiness was signed and aircraft was dispatched without placards being stuck on airspeed indicator as procedure calls out for. I failed to make sure the sticker was installed correctly when I put the logbook on aircraft. Supplemental information from acn 564088: on mon I was assigned to the tab foreplay inspection on aircraft X. The left tab failed and I proceeded to make the repair as required. When I finished I took the paperwork to the office to complete it. I then had some help filling out the logbook entry correctly because we were deferring the flight check for 30 days. When I had the logbook done I took the maintenance note placard and 2 airspeed restriction placards to place in the aircraft. At this time we had aircraft Y also in the hangar with a door mod being complied with. The tail of aircraft X was near the ladder of air carrier Y and I went to the cockpit of aircraft Y to placard the airspeed indicators and pedestal with the maintenance note. Im not sure what distracted me to the wrong aircraft, but I realized my mistake when I got home and was going over the events before I went to bed. I then notified maintenance control of the mistake. I'm sure that paying closer attention to the job at hand would have eliminated this situation. Callback conversation with reporter revealed the following information: the reporter stated the left elevator tab failed the foreplay inspection and the tab hinge bolts were replaced per the maintenance manual procedures. The reporter said the maintenance manual required a functional flight test and this was deferred per the MEL. The reporter stated the special procedures of the MEL required placarding the airspeed indicators limiting airspeed to .74 mach. The reporter said the technician placarding the airspeed indicators placarded the wrong airplane and the airplane with the tab repair was dispatched without the airspeed indicators placarded. The reporter stated he signed the maintenance release prior to dispatch but failed to check for placards.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH A FUNCTIONAL FLT TEST DEFERRED PER THE MEL BUT AIRSPEED PLACARDS OMITTED.
Narrative: WORKED OVERTIME ON HANGAR AND PERFORMED SVC CHK ON ACFT, TAB INSP WAS PERFORMED ON ACFT BY OTHER HANGAR PERSONNEL, ACFT REQUIRED MAINT NOTE TO CARRYOVER FUNCTIONAL FLT CHK DUE TO ELEVATOR TAB HINGE BOLT REPLACEMENT, LOGBOOK WAS DONE PROPERLY, BUT MEL STICKERS WERE NOT PLACED IN COCKPIT PROPERLY BY MECHANIC DOING MAINT NOTE ON ACFT. AIRWORTHINESS WAS SIGNED AND ACFT WAS DISPATCHED WITHOUT PLACARDS BEING STUCK ON AIRSPEED INDICATOR AS PROC CALLS OUT FOR. I FAILED TO MAKE SURE THE STICKER WAS INSTALLED CORRECTLY WHEN I PUT THE LOGBOOK ON ACFT. SUPPLEMENTAL INFO FROM ACN 564088: ON MON I WAS ASSIGNED TO THE TAB FOREPLAY INSPECTION ON ACFT X. THE LEFT TAB FAILED AND I PROCEEDED TO MAKE THE REPAIR AS REQUIRED. WHEN I FINISHED I TOOK THE PAPERWORK TO THE OFFICE TO COMPLETE IT. I THEN HAD SOME HELP FILLING OUT THE LOGBOOK ENTRY CORRECTLY BECAUSE WE WERE DEFERRING THE FLT CHK FOR 30 DAYS. WHEN I HAD THE LOGBOOK DONE I TOOK THE MAINT NOTE PLACARD AND 2 AIRSPEED RESTRICTION PLACARDS TO PLACE IN THE ACFT. AT THIS TIME WE HAD ACFT Y ALSO IN THE HANGAR WITH A DOOR MOD BEING COMPLIED WITH. THE TAIL OF ACFT X WAS NEAR THE LADDER OF ACR Y AND I WENT TO THE COCKPIT OF ACFT Y TO PLACARD THE AIRSPEED INDICATORS AND PEDESTAL WITH THE MAINT NOTE. IM NOT SURE WHAT DISTRACTED ME TO THE WRONG ACFT, BUT I REALIZED MY MISTAKE WHEN I GOT HOME AND WAS GOING OVER THE EVENTS BEFORE I WENT TO BED. I THEN NOTIFIED MAINT CTL OF THE MISTAKE. I'M SURE THAT PAYING CLOSER ATTENTION TO THE JOB AT HAND WOULD HAVE ELIMINATED THIS SIT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE L ELEVATOR TAB FAILED THE FOREPLAY INSPECTION AND THE TAB HINGE BOLTS WERE REPLACED PER THE MAINT MANUAL PROCS. THE RPTR SAID THE MAINT MANUAL REQUIRED A FUNCTIONAL FLT TEST AND THIS WAS DEFERRED PER THE MEL. THE RPTR STATED THE SPECIAL PROCS OF THE MEL REQUIRED PLACARDING THE AIRSPEED INDICATORS LIMITING AIRSPEED TO .74 MACH. THE RPTR SAID THE TECHNICIAN PLACARDING THE AIRSPEED INDICATORS PLACARDED THE WRONG AIRPLANE AND THE AIRPLANE WITH THE TAB REPAIR WAS DISPATCHED WITHOUT THE AIRSPEED INDICATORS PLACARDED. THE RPTR STATED HE SIGNED THE MAINT RELEASE PRIOR TO DISPATCH BUT FAILED TO CHK FOR PLACARDS.
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.