37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 598134 |
Time | |
Date | 200310 |
Day | Wed |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 23 |
ASRS Report | 598134 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : cabin pressure indicator other flight crewa other other : 4 |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
When I changed the seal, I firmly believed I read in amm 52-31-18 to fill all the holes with rtv (elastic sealant). I thought at the time it was odd, but did it the way I thought I had read it. I even mentioned it to my lead who said, if that's what the manual tells you to do it. Looking at a current amm reference, I do not see anything telling me to fill all the holes on the seal. I believe I must have misread that portion. I believe human factors played a major part in this incident as I am under a tremendous amount of pressure and stress. Since I left office management (particularly director mr X) and a few employees have attempted to set me up for termination, including possible sabotage. I have filed grievances (pending arbitration) and harassment eeo complaints, without result. My fellow crew members even feel the stress from this extremely hostile work environment. I am surprised I haven't made a mistake before this. This is the 1ST incident I have been involved in during my 17+ yrs at air carrier X. I believe this hostile environment must be stopped before we are investigating a major incident.
Original NASA ASRS Text
Title: AN AIRBUS RETURNED TO THE FIELD DUE TO FORWARD CARGO DOOR FAILURE. SEAL FOUND IMPROPERLY INSTALLED WITH INFLATION HOLES BLOCKED WITH SEALANT.
Narrative: WHEN I CHANGED THE SEAL, I FIRMLY BELIEVED I READ IN AMM 52-31-18 TO FILL ALL THE HOLES WITH RTV (ELASTIC SEALANT). I THOUGHT AT THE TIME IT WAS ODD, BUT DID IT THE WAY I THOUGHT I HAD READ IT. I EVEN MENTIONED IT TO MY LEAD WHO SAID, IF THAT'S WHAT THE MANUAL TELLS YOU TO DO IT. LOOKING AT A CURRENT AMM REF, I DO NOT SEE ANYTHING TELLING ME TO FILL ALL THE HOLES ON THE SEAL. I BELIEVE I MUST HAVE MISREAD THAT PORTION. I BELIEVE HUMAN FACTORS PLAYED A MAJOR PART IN THIS INCIDENT AS I AM UNDER A TREMENDOUS AMOUNT OF PRESSURE AND STRESS. SINCE I LEFT OFFICE MGMNT (PARTICULARLY DIRECTOR MR X) AND A FEW EMPLOYEES HAVE ATTEMPTED TO SET ME UP FOR TERMINATION, INCLUDING POSSIBLE SABOTAGE. I HAVE FILED GRIEVANCES (PENDING ARBITRATION) AND HARASSMENT EEO COMPLAINTS, WITHOUT RESULT. MY FELLOW CREW MEMBERS EVEN FEEL THE STRESS FROM THIS EXTREMELY HOSTILE WORK ENVIRONMENT. I AM SURPRISED I HAVEN'T MADE A MISTAKE BEFORE THIS. THIS IS THE 1ST INCIDENT I HAVE BEEN INVOLVED IN DURING MY 17+ YRS AT ACR X. I BELIEVE THIS HOSTILE ENVIRONMENT MUST BE STOPPED BEFORE WE ARE INVESTIGATING A MAJOR INCIDENT.
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.