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|
Attributes | |
ACN | 582704 |
Time | |
Date | 200305 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : c90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 6 |
ASRS Report | 582704 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Flight Crew Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
While finishing ETOPS 1 gate check items on aircraft, the copt gave me the forward cargo compartment control panel door that he found in the cockpit. I examined the door noticing that everything was alright except 1 of the 2 latches were bent a little, but still operable. Without reading the logbook well, I reinstalled the door, assuming the plane would be better off with the door installed until the bent latch could be replaced. I speed taped the bent latch just to make sure the latch would not open. I thought this way the door would not get lost. At no time did I think the installation of the door created a dangerous condition. I thought the latch could be changed later and the cdl (confign deviation list) cleared. The plane left and a few days later, one of my mgrs called saying the FAA had called about the door. After a few seconds, I realized my mistake. I should have clearly read the logbook and cdl saying the door was taken off for a reason. I guess my lack of experience in this type of situation and the fact that the plane was going out soon made me rush and make a bad decision. Believe me, I have not stopped thinking about this situation and will be sure to take my time and not make this type of mistake again.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH A CARGO DOOR CTL PANEL DOOR REINSTALLED IN CONFLICT WITH THE CONFIGN DEV LIST.
Narrative: WHILE FINISHING ETOPS 1 GATE CHK ITEMS ON ACFT, THE COPT GAVE ME THE FORWARD CARGO COMPARTMENT CTL PANEL DOOR THAT HE FOUND IN THE COCKPIT. I EXAMINED THE DOOR NOTICING THAT EVERYTHING WAS ALRIGHT EXCEPT 1 OF THE 2 LATCHES WERE BENT A LITTLE, BUT STILL OPERABLE. WITHOUT READING THE LOGBOOK WELL, I REINSTALLED THE DOOR, ASSUMING THE PLANE WOULD BE BETTER OFF WITH THE DOOR INSTALLED UNTIL THE BENT LATCH COULD BE REPLACED. I SPEED TAPED THE BENT LATCH JUST TO MAKE SURE THE LATCH WOULD NOT OPEN. I THOUGHT THIS WAY THE DOOR WOULD NOT GET LOST. AT NO TIME DID I THINK THE INSTALLATION OF THE DOOR CREATED A DANGEROUS CONDITION. I THOUGHT THE LATCH COULD BE CHANGED LATER AND THE CDL (CONFIGN DEV LIST) CLRED. THE PLANE LEFT AND A FEW DAYS LATER, ONE OF MY MGRS CALLED SAYING THE FAA HAD CALLED ABOUT THE DOOR. AFTER A FEW SECONDS, I REALIZED MY MISTAKE. I SHOULD HAVE CLRLY READ THE LOGBOOK AND CDL SAYING THE DOOR WAS TAKEN OFF FOR A REASON. I GUESS MY LACK OF EXPERIENCE IN THIS TYPE OF SIT AND THE FACT THAT THE PLANE WAS GOING OUT SOON MADE ME RUSH AND MAKE A BAD DECISION. BELIEVE ME, I HAVE NOT STOPPED THINKING ABOUT THIS SIT AND WILL BE SURE TO TAKE MY TIME AND NOT MAKE THIS TYPE OF MISTAKE AGAIN.
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.