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|
Attributes | |
ACN | 570852 |
Time | |
Date | 200301 |
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 | Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B717 (Formerly MD-95) |
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 | 570852 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : anomaly accepted |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards contributing factor : engineering procedure performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Company Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Engineering Order |
Narrative:
On jan/tue/03, I received engineering order. After a brief review, I realized problems. First, there were xerox copies of computer scanned pictures that I could not comprehend. There were references to pipe assemblies that I could not identify. Also in the illustrations, I could not identify the reference to support wiring (step 1.2.5). Even after looking at the aircraft, I still had a hard time understanding what was going on, because the illustrations on the engineering order were bad. I consulted the engineer involved, and he proceeded to show me on his computer a beautiful colored picture of the components/area involved. I immediately pointed out that on the right illustration, it showed a wire harness, but on the aircraft, the harness was rted differently. Step 1.2.5 explicitly says to 'support wires as shown in figure 839, when in actuality, these 'wires' aren't there! On step 1.3.23 and 1.3.29, the illustration only shows the left side. However, it has a note in figure 5 that says 'the tube assembly for the water drain convection is shown installed on the refrigeration unit used on the l-hand aircraft installation. Make sure the tube assembly and cap are reversed in the r-hand aircraft installation.' the way I see it -- if the valve on the left and right were symmetrical -- fine! But, the right is 30 degrees different, this puts '4' ports in a rotation that is hard to interpretation. On steps 1.3.29/1.2.23 for tubes, because the right mix/muff is turned 30 degrees (approximately), they do not fit, however, on the left -- they fall into place. After consulting with the engineer, he said the right side should mirror the left, so why are you having a problem!? I insisted that he look at the aircraft. After coming downstairs to take a look, he agreed it was different! I suggested that, perhaps the right should require a different part number for tubes, because of the rotation of the mix/muff. At this point, the director/supervisor was looking over our shoulders. He expressed that we make it fit -- after nudging me aside, he proceeded to physically hand 'yank and pull' on the tubing to 'make it fit.' in fact, I commented on 1 of those pulls 'I saw your knuckles turning white!' on steps 1.3.31 through 1.3.38, required clamping of the new lines (tubes) with references to existing lines. On the left side there was no problem, lines and clamp were installed exactly like the illustrations. However, on the right -- there was a problem, because of the rotation of the 'mixing muff' and the 'messaging' that 'we' did on the lines, did not intersect any other lines, and the engineering order did not illustrate any special conditions for the right. The engineer, even though he claims he received this engineering order from another air line, still doesn't justify us doing if wrong -- he (engineer) never read the engineering order! He never stepped foot in the aircraft.
Original NASA ASRS Text
Title: A B717 AIR CONDITIONING MIXING MUFF MODIFICATION JOB CARD IS RPTED TO BE WRITTEN IN A DISORDERED AND UNCERTAIN MANNER.
Narrative: ON JAN/TUE/03, I RECEIVED ENGINEERING ORDER. AFTER A BRIEF REVIEW, I REALIZED PROBS. FIRST, THERE WERE XEROX COPIES OF COMPUTER SCANNED PICTURES THAT I COULD NOT COMPREHEND. THERE WERE REFS TO PIPE ASSEMBLIES THAT I COULD NOT IDENT. ALSO IN THE ILLUSTRATIONS, I COULD NOT IDENT THE REF TO SUPPORT WIRING (STEP 1.2.5). EVEN AFTER LOOKING AT THE ACFT, I STILL HAD A HARD TIME UNDERSTANDING WHAT WAS GOING ON, BECAUSE THE ILLUSTRATIONS ON THE ENGINEERING ORDER WERE BAD. I CONSULTED THE ENGINEER INVOLVED, AND HE PROCEEDED TO SHOW ME ON HIS COMPUTER A BEAUTIFUL COLORED PICTURE OF THE COMPONENTS/AREA INVOLVED. I IMMEDIATELY POINTED OUT THAT ON THE R ILLUSTRATION, IT SHOWED A WIRE HARNESS, BUT ON THE ACFT, THE HARNESS WAS RTED DIFFERENTLY. STEP 1.2.5 EXPLICITLY SAYS TO 'SUPPORT WIRES AS SHOWN IN FIGURE 839, WHEN IN ACTUALITY, THESE 'WIRES' AREN'T THERE! ON STEP 1.3.23 AND 1.3.29, THE ILLUSTRATION ONLY SHOWS THE L SIDE. HOWEVER, IT HAS A NOTE IN FIGURE 5 THAT SAYS 'THE TUBE ASSEMBLY FOR THE WATER DRAIN CONVECTION IS SHOWN INSTALLED ON THE REFRIGERATION UNIT USED ON THE L-HAND ACFT INSTALLATION. MAKE SURE THE TUBE ASSEMBLY AND CAP ARE REVERSED IN THE R-HAND ACFT INSTALLATION.' THE WAY I SEE IT -- IF THE VALVE ON THE L AND R WERE SYMMETRICAL -- FINE! BUT, THE R IS 30 DEGS DIFFERENT, THIS PUTS '4' PORTS IN A ROTATION THAT IS HARD TO INTERP. ON STEPS 1.3.29/1.2.23 FOR TUBES, BECAUSE THE R MIX/MUFF IS TURNED 30 DEGS (APPROX), THEY DO NOT FIT, HOWEVER, ON THE L -- THEY FALL INTO PLACE. AFTER CONSULTING WITH THE ENGINEER, HE SAID THE R SIDE SHOULD MIRROR THE L, SO WHY ARE YOU HAVING A PROB!? I INSISTED THAT HE LOOK AT THE ACFT. AFTER COMING DOWNSTAIRS TO TAKE A LOOK, HE AGREED IT WAS DIFFERENT! I SUGGESTED THAT, PERHAPS THE R SHOULD REQUIRE A DIFFERENT PART NUMBER FOR TUBES, BECAUSE OF THE ROTATION OF THE MIX/MUFF. AT THIS POINT, THE DIRECTOR/SUPVR WAS LOOKING OVER OUR SHOULDERS. HE EXPRESSED THAT WE MAKE IT FIT -- AFTER NUDGING ME ASIDE, HE PROCEEDED TO PHYSICALLY HAND 'YANK AND PULL' ON THE TUBING TO 'MAKE IT FIT.' IN FACT, I COMMENTED ON 1 OF THOSE PULLS 'I SAW YOUR KNUCKLES TURNING WHITE!' ON STEPS 1.3.31 THROUGH 1.3.38, REQUIRED CLAMPING OF THE NEW LINES (TUBES) WITH REFS TO EXISTING LINES. ON THE L SIDE THERE WAS NO PROB, LINES AND CLAMP WERE INSTALLED EXACTLY LIKE THE ILLUSTRATIONS. HOWEVER, ON THE R -- THERE WAS A PROB, BECAUSE OF THE ROTATION OF THE 'MIXING MUFF' AND THE 'MESSAGING' THAT 'WE' DID ON THE LINES, DID NOT INTERSECT ANY OTHER LINES, AND THE ENGINEERING ORDER DID NOT ILLUSTRATE ANY SPECIAL CONDITIONS FOR THE R. THE ENGINEER, EVEN THOUGH HE CLAIMS HE RECEIVED THIS ENGINEERING ORDER FROM ANOTHER AIR LINE, STILL DOESN'T JUSTIFY US DOING IF WRONG -- HE (ENGINEER) NEVER READ THE ENGINEERING ORDER! HE NEVER STEPPED FOOT IN THE ACFT.
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.