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Attributes | |
ACN | 574141 |
Time | |
Date | 200302 |
Day | Sat |
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 | B737-300 |
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 | 574141 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
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 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Chart Or Publication Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Acft Order Job Card |
Narrative:
At the start of my shift, I checked in with 2 or 3 mechanics, who had been working on the psu reconfign for XXXX. I was told that they had tried to sell psu reconfign to grave shift inspector, and that the only problem was with the oxygen mask drop dimensions on the R14 side of the aircraft. I was told the masks were dropping to close to the seat backs of the next row forward. I was told that all psu's, which required swapping from 1 side of aircraft to the other had been accomplished. 1 of my clock-INS was working a double shift so he and I proceeded to identify the problem. We began by looking at drawing X, and determined that the wrong width spacer panel had been installed just forward of rih sta 348. (It was a 4 inch wide spacer and a 5 inch wide spacer was required.) we then installed correct spacer and shifted remaining spacers and psu's through the cabin, checking each as we went. We then checked the oxygen mask, dropped dimensions pen drawing page 1, which were correct, and then sold that to inspection. The aco does not have individual sign-offs for each psu, which requires swapping from 1 location to another in the aircraft. Also, instructions in step 1.a.(1) are not correct/clear as to all tasks required for new confign.
Original NASA ASRS Text
Title: A B737-300 RECONFIGN OF PAX SVC UNITS WAS ACCOMPLISHED INCORRECTLY DUE TO THE JOB CARD DEFICIENCY. FOUND OXYGEN MASKS OUT OF PAX REACH.
Narrative: AT THE START OF MY SHIFT, I CHKED IN WITH 2 OR 3 MECHS, WHO HAD BEEN WORKING ON THE PSU RECONFIGN FOR XXXX. I WAS TOLD THAT THEY HAD TRIED TO SELL PSU RECONFIGN TO GRAVE SHIFT INSPECTOR, AND THAT THE ONLY PROB WAS WITH THE OXYGEN MASK DROP DIMENSIONS ON THE R14 SIDE OF THE ACFT. I WAS TOLD THE MASKS WERE DROPPING TO CLOSE TO THE SEAT BACKS OF THE NEXT ROW FORWARD. I WAS TOLD THAT ALL PSU'S, WHICH REQUIRED SWAPPING FROM 1 SIDE OF ACFT TO THE OTHER HAD BEEN ACCOMPLISHED. 1 OF MY CLOCK-INS WAS WORKING A DOUBLE SHIFT SO HE AND I PROCEEDED TO IDENT THE PROB. WE BEGAN BY LOOKING AT DRAWING X, AND DETERMINED THAT THE WRONG WIDTH SPACER PANEL HAD BEEN INSTALLED JUST FORWARD OF RIH STA 348. (IT WAS A 4 INCH WIDE SPACER AND A 5 INCH WIDE SPACER WAS REQUIRED.) WE THEN INSTALLED CORRECT SPACER AND SHIFTED REMAINING SPACERS AND PSU'S THROUGH THE CABIN, CHKING EACH AS WE WENT. WE THEN CHKED THE OXYGEN MASK, DROPPED DIMENSIONS PEN DRAWING PAGE 1, WHICH WERE CORRECT, AND THEN SOLD THAT TO INSPECTION. THE ACO DOES NOT HAVE INDIVIDUAL SIGN-OFFS FOR EACH PSU, WHICH REQUIRES SWAPPING FROM 1 LOCATION TO ANOTHER IN THE ACFT. ALSO, INSTRUCTIONS IN STEP 1.A.(1) ARE NOT CORRECT/CLR AS TO ALL TASKS REQUIRED FOR NEW CONFIGN.
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.