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Attributes | |
ACN | 592298 |
Time | |
Date | 200308 |
Day | Thu |
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 | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician oversight : supervisor |
Qualification | technician : powerplant technician : airframe technician : inspection authority |
Experience | maintenance supervisor : 11 |
ASRS Report | 592298 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 5 |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : logbook entry performance deficiency : training performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
On the morning of aug/thu/03, I reviewed the logbook and task cards for aircraft in accordance with the audit procedures stated in our company gmm chapter 5 section 1.3G steps 1A, 1B, and 1C. Satisfied that the task cards and log pages were completed and properly signed off, I proceeded to sign off the aircraft release in accordance with airworthiness release procedures stated in our gmm chapter 4 section 1.5C steps 1, 2, and 3 and 1.5F steps 1 and 2. Aircraft flight departs to ZZZ1 at XA50 aug/thu/03. About XC00 I was contacted by air carrier maintenance manager mr X and air carrier Y stores supervisor mr Y into mr X's office. They had informed me that a wrong part number maintenance aircraft battery might be installed in aircraft. They showed me an air carrier Y 8130 tag with the part number installed part X with the removed unit was part number part Y. I immediately went back to our office and looked back at the log pages and found the entry for the main battery replacement and noticed part number on was a part Y and removed unit was part Y. Realizing that the log page (#62 page 013743) was correct with our procedures, I called company maintenance and spoke with technician. I explained the situation and from his review of the log pages everything seemed normal. Part number for battery was part Y for on and off units. I showed mr X and mr Y the log page and we all came to a conclusion that the battery installed was part X. We had confirmed with the 8130 and with stores inventory that the wrong battery part number was installed. I called company maintenance back and told them that we have definite confirmation that the wrong battery was installed. Company maintenance immediately called senior director quality assurance and confirmed the ipc was the determining factor for conformity and that we needed to call aircraft X back to ZZZ. Aircraft arrived back to ZZZ about XE35 and the main battery was replaced in accordance with task card 24-006-01. ETOPS 1 reaccomplished and aircraft departed. Air carrier Y maintenance technician had installed the wrong part number battery and signed off the work accomplished with the correct part number. With no air carrier Y stores personnel available at night, I would like to recommend more air carrier Y lead technician involvement for distribution of parts.
Original NASA ASRS Text
Title: A B767-300ER WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT MAIN SHIPS BATTERY INSTALLED. FLT DIVERTED AFTER DISCOVERY.
Narrative: ON THE MORNING OF AUG/THU/03, I REVIEWED THE LOGBOOK AND TASK CARDS FOR ACFT IN ACCORDANCE WITH THE AUDIT PROCS STATED IN OUR COMPANY GMM CHAPTER 5 SECTION 1.3G STEPS 1A, 1B, AND 1C. SATISFIED THAT THE TASK CARDS AND LOG PAGES WERE COMPLETED AND PROPERLY SIGNED OFF, I PROCEEDED TO SIGN OFF THE ACFT RELEASE IN ACCORDANCE WITH AIRWORTHINESS RELEASE PROCS STATED IN OUR GMM CHAPTER 4 SECTION 1.5C STEPS 1, 2, AND 3 AND 1.5F STEPS 1 AND 2. ACFT FLT DEPARTS TO ZZZ1 AT XA50 AUG/THU/03. ABOUT XC00 I WAS CONTACTED BY ACR MAINT MGR MR X AND ACR Y STORES SUPVR MR Y INTO MR X'S OFFICE. THEY HAD INFORMED ME THAT A WRONG PART NUMBER MAINT ACFT BATTERY MIGHT BE INSTALLED IN ACFT. THEY SHOWED ME AN ACR Y 8130 TAG WITH THE PART NUMBER INSTALLED PART X WITH THE REMOVED UNIT WAS PART NUMBER PART Y. I IMMEDIATELY WENT BACK TO OUR OFFICE AND LOOKED BACK AT THE LOG PAGES AND FOUND THE ENTRY FOR THE MAIN BATTERY REPLACEMENT AND NOTICED PART NUMBER ON WAS A PART Y AND REMOVED UNIT WAS PART Y. REALIZING THAT THE LOG PAGE (#62 PAGE 013743) WAS CORRECT WITH OUR PROCS, I CALLED COMPANY MAINT AND SPOKE WITH TECHNICIAN. I EXPLAINED THE SIT AND FROM HIS REVIEW OF THE LOG PAGES EVERYTHING SEEMED NORMAL. PART NUMBER FOR BATTERY WAS PART Y FOR ON AND OFF UNITS. I SHOWED MR X AND MR Y THE LOG PAGE AND WE ALL CAME TO A CONCLUSION THAT THE BATTERY INSTALLED WAS PART X. WE HAD CONFIRMED WITH THE 8130 AND WITH STORES INVENTORY THAT THE WRONG BATTERY PART NUMBER WAS INSTALLED. I CALLED COMPANY MAINT BACK AND TOLD THEM THAT WE HAVE DEFINITE CONFIRMATION THAT THE WRONG BATTERY WAS INSTALLED. COMPANY MAINT IMMEDIATELY CALLED SENIOR DIRECTOR QUALITY ASSURANCE AND CONFIRMED THE IPC WAS THE DETERMINING FACTOR FOR CONFORMITY AND THAT WE NEEDED TO CALL ACFT X BACK TO ZZZ. ACFT ARRIVED BACK TO ZZZ ABOUT XE35 AND THE MAIN BATTERY WAS REPLACED IN ACCORDANCE WITH TASK CARD 24-006-01. ETOPS 1 REACCOMPLISHED AND ACFT DEPARTED. ACR Y MAINT TECHNICIAN HAD INSTALLED THE WRONG PART NUMBER BATTERY AND SIGNED OFF THE WORK ACCOMPLISHED WITH THE CORRECT PART NUMBER. WITH NO ACR Y STORES PERSONNEL AVAILABLE AT NIGHT, I WOULD LIKE TO RECOMMEND MORE ACR Y LEAD TECHNICIAN INVOLVEMENT FOR DISTRIBUTION OF PARTS.
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.