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An a&P technician mixes the incorrect ratio of water to disinfectant for a solution to disinfect a 50 gal tank rather than that required for a 60 gal container at ZZZ, us.
| Attributes | |
| ACN | 591672 |
| Time | |
| Date | 200308 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 591672 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies other anomaly other |
| Independent Detector | other other : gnd 1 |
| Resolutory Action | none taken : detected after the fact |
| Supplementary | |
| Problem Areas | Company Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Found that I had misread the instruction on a work card. I had mixed a solution for a 50 gal water tank rather than a 60 gal tank. I had referenced a maintenance manual on the log page which was the same as the method used on a work card, for an alternate method for mixing a disinfectant solution. Reference maintenance manual 38-10-00 page 200. Reference task card X air carrier X B737, ie. I feel that lack of training by company has also played a part in this as a situation.
Original NASA ASRS Text
Title: AN A&P TECHNICIAN MIXES THE INCORRECT RATIO OF WATER TO DISINFECTANT FOR A SOLUTION TO DISINFECT A 50 GAL TANK RATHER THAN THAT REQUIRED FOR A 60 GAL CONTAINER AT ZZZ, US.
Narrative: FOUND THAT I HAD MISREAD THE INSTRUCTION ON A WORK CARD. I HAD MIXED A SOLUTION FOR A 50 GAL WATER TANK RATHER THAN A 60 GAL TANK. I HAD REFED A MAINT MANUAL ON THE LOG PAGE WHICH WAS THE SAME AS THE METHOD USED ON A WORK CARD, FOR AN ALTERNATE METHOD FOR MIXING A DISINFECTANT SOLUTION. REF MAINT MANUAL 38-10-00 PAGE 200. REF TASK CARD X ACR X B737, IE. I FEEL THAT LACK OF TRAINING BY COMPANY HAS ALSO PLAYED A PART IN THIS AS A SIT.
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.