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|
Attributes | |
ACN | 581526 |
Time | |
Date | 200304 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
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 | B767-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 15 |
ASRS Report | 581526 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : testing |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Environmental Factor Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Fire Bottle Repl Proc |
Narrative:
Aircraft X flew into ZZZ for a 'C' check. Mechanics there working on a job card to test the cargo fire extinguishing system apparently found the cannon plug for the pressure switch disconnected on the cargo compartment fire bottle. Upon further investigation, it was found that the fire bottle had recently been changed at ZZZ1. I was the mechanic that changed the bottle and signed off the job card for the removal and installation of a cargo compartment bottle. I was in a hurry to complete the job since I had lost time trying to locate the correct part number of the fire bottle. Also, I was distracted during the installation of the cargo fire bottle because of a discrepancy I found (and tried to correct) with the engine fire bottles (located just aft of the cargo fire bottle). During all of this I may have left the cannon plug off of the pressure switch on the cargo compartment fire bottle. The pressure switch only detects a decrease in pressure and activates the bottle discharge lights after the bottle has been fired. I had performed a test of the squibs on the fire bottle which tested normal. (This indicates that the fire bottle still would have worked in the event of an emergency.) but, I may not have performed the test of the pressure switch on the bottle.
Original NASA ASRS Text
Title: A B767-200 WAS DISPATCHED IN NON COMPLIANCE AFTER THE REPLACEMENT OF A CARGO COMPARTMENT FIRE BOTTLE. LATER DISCOVERED THE BOTTLE PRESSURE SWITCH WAS NOT CONNECTED.
Narrative: ACFT X FLEW INTO ZZZ FOR A 'C' CHK. MECHS THERE WORKING ON A JOB CARD TO TEST THE CARGO FIRE EXTINGUISHING SYS APPARENTLY FOUND THE CANNON PLUG FOR THE PRESSURE SWITCH DISCONNECTED ON THE CARGO COMPARTMENT FIRE BOTTLE. UPON FURTHER INVESTIGATION, IT WAS FOUND THAT THE FIRE BOTTLE HAD RECENTLY BEEN CHANGED AT ZZZ1. I WAS THE MECH THAT CHANGED THE BOTTLE AND SIGNED OFF THE JOB CARD FOR THE REMOVAL AND INSTALLATION OF A CARGO COMPARTMENT BOTTLE. I WAS IN A HURRY TO COMPLETE THE JOB SINCE I HAD LOST TIME TRYING TO LOCATE THE CORRECT PART NUMBER OF THE FIRE BOTTLE. ALSO, I WAS DISTRACTED DURING THE INSTALLATION OF THE CARGO FIRE BOTTLE BECAUSE OF A DISCREPANCY I FOUND (AND TRIED TO CORRECT) WITH THE ENG FIRE BOTTLES (LOCATED JUST AFT OF THE CARGO FIRE BOTTLE). DURING ALL OF THIS I MAY HAVE LEFT THE CANNON PLUG OFF OF THE PRESSURE SWITCH ON THE CARGO COMPARTMENT FIRE BOTTLE. THE PRESSURE SWITCH ONLY DETECTS A DECREASE IN PRESSURE AND ACTIVATES THE BOTTLE DISCHARGE LIGHTS AFTER THE BOTTLE HAS BEEN FIRED. I HAD PERFORMED A TEST OF THE SQUIBS ON THE FIRE BOTTLE WHICH TESTED NORMAL. (THIS INDICATES THAT THE FIRE BOTTLE STILL WOULD HAVE WORKED IN THE EVENT OF AN EMER.) BUT, I MAY NOT HAVE PERFORMED THE TEST OF THE PRESSURE SWITCH ON THE BOTTLE.
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.