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|
Attributes | |
ACN | 595700 |
Time | |
Date | 200310 |
Day | Wed |
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 | |
Operator | common carrier : air carrier |
Make Model Name | B747-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance avionics : 13 maintenance lead technician : 18 maintenance technician : 26 |
ASRS Report | 595700 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
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 other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Air carrier X airlines flight a from ZZZZ arrived late after diverting to ZZZ1 due to fog at ZZZ. A work package was assigned to the aircraft which included a brake change for #5 main brake assembly. The crew working the aircraft was assigned the brake change. As the lead technician, I determined that there was not enough time to accomplish the line check so I called maintenance control to reschedule the line check. When the aircraft finally arrived from ZZZ1, the a&P crew began the brake change and I did the turn-around check. After completing the walkaround, I wrote down the tracking tag number and serial number for the parts change. I then assisted the avionics technicians who were working the cabin write-ups. When the a&P crew informed me that the brake was ready for leak and operations checks, by radio, I pressurized hydraulics and set brakes and pumped brake pedals for leak and operations checks. I was informed by radio that the brake checked ok, so I signed for the brake change in the aircraft logbook and the work package paperwork. On oct/tue/03 I was informed by the crew that was working the same aircraft that the logbook had a write-up for changing #5 brake in ZZZ2 due to wrong part installed. So I checked the computer records and found that I had signed for installing the wrong stock number brake. (ZZZZ2 changed to the correct brake on oct/sat/03.)
Original NASA ASRS Text
Title: A B747-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT #5 BRAKE INSTALLED. BRAKE LATER REPLACED AFTER INCORRECT PART DISCOVERY.
Narrative: ACR X AIRLINES FLT A FROM ZZZZ ARRIVED LATE AFTER DIVERTING TO ZZZ1 DUE TO FOG AT ZZZ. A WORK PACKAGE WAS ASSIGNED TO THE ACFT WHICH INCLUDED A BRAKE CHANGE FOR #5 MAIN BRAKE ASSEMBLY. THE CREW WORKING THE ACFT WAS ASSIGNED THE BRAKE CHANGE. AS THE LEAD TECHNICIAN, I DETERMINED THAT THERE WAS NOT ENOUGH TIME TO ACCOMPLISH THE LINE CHK SO I CALLED MAINT CTL TO RESCHEDULE THE LINE CHK. WHEN THE ACFT FINALLY ARRIVED FROM ZZZ1, THE A&P CREW BEGAN THE BRAKE CHANGE AND I DID THE TURN-AROUND CHK. AFTER COMPLETING THE WALKAROUND, I WROTE DOWN THE TRACKING TAG NUMBER AND SERIAL NUMBER FOR THE PARTS CHANGE. I THEN ASSISTED THE AVIONICS TECHNICIANS WHO WERE WORKING THE CABIN WRITE-UPS. WHEN THE A&P CREW INFORMED ME THAT THE BRAKE WAS READY FOR LEAK AND OPS CHKS, BY RADIO, I PRESSURIZED HYDS AND SET BRAKES AND PUMPED BRAKE PEDALS FOR LEAK AND OPS CHKS. I WAS INFORMED BY RADIO THAT THE BRAKE CHKED OK, SO I SIGNED FOR THE BRAKE CHANGE IN THE ACFT LOGBOOK AND THE WORK PACKAGE PAPERWORK. ON OCT/TUE/03 I WAS INFORMED BY THE CREW THAT WAS WORKING THE SAME ACFT THAT THE LOGBOOK HAD A WRITE-UP FOR CHANGING #5 BRAKE IN ZZZ2 DUE TO WRONG PART INSTALLED. SO I CHKED THE COMPUTER RECORDS AND FOUND THAT I HAD SIGNED FOR INSTALLING THE WRONG STOCK NUMBER BRAKE. (ZZZZ2 CHANGED TO THE CORRECT BRAKE ON OCT/SAT/03.)
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.