37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 590493 |
Time | |
Date | 200308 |
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 | |
Controlling Facilities | tower : ord.tower |
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 |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 14 |
ASRS Report | 590493 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : fcc technician : powerplant technician : airframe |
Experience | maintenance avionics : 15 maintenance lead technician : 7 maintenance technician : 8 |
ASRS Report | 590867 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Job Card |
Narrative:
I was assigned to work #1 engine on aircraft X. While performing an engine mount bolt inspection work card, operation X the bolts being checked were found to have missing and deteriorated torque stripes. The card in work referred me to another operation, operation (Y), if this condition was found. The first operation was not designated rii (required inspection item). When the inspection/work on operation (Y) was completed, I signed off the inspection slots on the card. I did not realize at the time that this card, operation Y was an rii card. At the time I was not aware of the way that this card was designated rii, it was different than I had previously seen. I was only familiar with rii being in bold print next to the signature block for each item requiring an rii qualifications. This card had the rii in regular print in the upper right corner, and on the back of the card in the 'short sign' area. My shift ended (dayshift) and I went home. The next day I was told of my mistake and that the error was found by our people that audit the cards, before the plane was put back in service.
Original NASA ASRS Text
Title: A B767-200 L ENG MOUNT BOLT TORQUE STRIPES INSPECTION AND OP WAS COMPLETED, BUT THE REQUIRED FAA INSPECTION WAS NOT ACCOMPLISHED.
Narrative: I WAS ASSIGNED TO WORK #1 ENG ON ACFT X. WHILE PERFORMING AN ENG MOUNT BOLT INSPECTION WORK CARD, OP X THE BOLTS BEING CHKED WERE FOUND TO HAVE MISSING AND DETERIORATED TORQUE STRIPES. THE CARD IN WORK REFERRED ME TO ANOTHER OP, OP (Y), IF THIS CONDITION WAS FOUND. THE FIRST OP WAS NOT DESIGNATED RII (REQUIRED INSPECTION ITEM). WHEN THE INSPECTION/WORK ON OP (Y) WAS COMPLETED, I SIGNED OFF THE INSPECTION SLOTS ON THE CARD. I DID NOT REALIZE AT THE TIME THAT THIS CARD, OP Y WAS AN RII CARD. AT THE TIME I WAS NOT AWARE OF THE WAY THAT THIS CARD WAS DESIGNATED RII, IT WAS DIFFERENT THAN I HAD PREVIOUSLY SEEN. I WAS ONLY FAMILIAR WITH RII BEING IN BOLD PRINT NEXT TO THE SIGNATURE BLOCK FOR EACH ITEM REQUIRING AN RII QUALIFICATIONS. THIS CARD HAD THE RII IN REGULAR PRINT IN THE UPPER R CORNER, AND ON THE BACK OF THE CARD IN THE 'SHORT SIGN' AREA. MY SHIFT ENDED (DAYSHIFT) AND I WENT HOME. THE NEXT DAY I WAS TOLD OF MY MISTAKE AND THAT THE ERROR WAS FOUND BY OUR PEOPLE THAT AUDIT THE CARDS, BEFORE THE PLANE WAS PUT BACK IN SVC.
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.