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|
Attributes | |
ACN | 594028 |
Time | |
Date | 200309 |
Day | Thu |
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 | Fokker 100 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 594028 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 594029 |
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 : work cards performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : testing performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft was found to have 2 cannon plugs for cargo fire bottle disconnected and not safetied during open up of current visit at ZZZ1. My signature was on a accomplishment portion of work card from last visit 2 yrs ago I do not specifically remember this visit, but do remember doing that check many times. I signed the work card, but do not recall whether my partner or myself actually connected and safetied the other bottles I should not have signed the box for the whole check without first making sure the cannon plugs were reconnected. In retrospect, it is unfortunate that this was not noticed on close up. Callback conversation with reporter revealed the following information: the reporter stated an investigation was held and the reporter was advised maintenance records indicated this involvement with installing and testing the forward cargo fire extinguisher bottles. The reporter said the records were two yrs old and could remember little or nothing of the job, but it was his initials on the job card. The reporter stated the system is tested from the cockpit and tests the wiring circuit, but not the bottle squib. The reporter said the only work accomplished in the area of the bottles after leaving the heavy maintenance check was a sheet metal repair. The reporter stated a large fuselage skin repair 2 ft by 2 ft was accomplished and the bottles had to be removed for access and this is where the plugs may have been disconnected and not reconnected. The reporter said paperwork on the sheet metal repair was checked and no write-ups were made for the bottle removal, reinstallation and test. The reporter stated this is normal as the sheet metal repair was accomplished using a structures engineer written repair and normally starts out as 'gain access to the interior skin and stringers' the reporter said gaining access to the interior skin and stringers meant bottle removal.
Original NASA ASRS Text
Title: A FOKKER 100 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE FOR TWO YRS WITH TWO CARGO COMPARTMENT FIRE EXTINGUISHER BOTTLE CONNECTORS DISCONNECTED.
Narrative: ACFT WAS FOUND TO HAVE 2 CANNON PLUGS FOR CARGO FIRE BOTTLE DISCONNECTED AND NOT SAFETIED DURING OPEN UP OF CURRENT VISIT AT ZZZ1. MY SIGNATURE WAS ON A ACCOMPLISHMENT PORTION OF WORK CARD FROM LAST VISIT 2 YRS AGO I DO NOT SPECIFICALLY REMEMBER THIS VISIT, BUT DO REMEMBER DOING THAT CHECK MANY TIMES. I SIGNED THE WORK CARD, BUT DO NOT RECALL WHETHER MY PARTNER OR MYSELF ACTUALLY CONNECTED AND SAFETIED THE OTHER BOTTLES I SHOULD NOT HAVE SIGNED THE BOX FOR THE WHOLE CHECK WITHOUT FIRST MAKING SURE THE CANNON PLUGS WERE RECONNECTED. IN RETROSPECT, IT IS UNFORTUNATE THAT THIS WAS NOT NOTICED ON CLOSE UP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED AN INVESTIGATION WAS HELD AND THE RPTR WAS ADVISED MAINT RECORDS INDICATED THIS INVOLVEMENT WITH INSTALLING AND TESTING THE FORWARD CARGO FIRE EXTINGUISHER BOTTLES. THE RPTR SAID THE RECORDS WERE TWO YRS OLD AND COULD REMEMBER LITTLE OR NOTHING OF THE JOB, BUT IT WAS HIS INITIALS ON THE JOB CARD. THE RPTR STATED THE SYSTEM IS TESTED FROM THE COCKPIT AND TESTS THE WIRING CIRCUIT, BUT NOT THE BOTTLE SQUIB. THE RPTR SAID THE ONLY WORK ACCOMPLISHED IN THE AREA OF THE BOTTLES AFTER LEAVING THE HEAVY MAINT CHECK WAS A SHEET METAL REPAIR. THE RPTR STATED A LARGE FUSELAGE SKIN REPAIR 2 FT BY 2 FT WAS ACCOMPLISHED AND THE BOTTLES HAD TO BE REMOVED FOR ACCESS AND THIS IS WHERE THE PLUGS MAY HAVE BEEN DISCONNECTED AND NOT RECONNECTED. THE RPTR SAID PAPERWORK ON THE SHEET METAL REPAIR WAS CHECKED AND NO WRITE-UPS WERE MADE FOR THE BOTTLE REMOVAL, REINSTALLATION AND TEST. THE RPTR STATED THIS IS NORMAL AS THE SHEET METAL REPAIR WAS ACCOMPLISHED USING A STRUCTURES ENGINEER WRITTEN REPAIR AND NORMALLY STARTS OUT AS 'GAIN ACCESS TO THE INTERIOR SKIN AND STRINGERS' THE RPTR SAID GAINING ACCESS TO THE INTERIOR SKIN AND STRINGERS MEANT BOTTLE REMOVAL.
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.